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CLINICAL    LECTURES 


PRACTICE    OF    MEDICINE. 


By  the  Editor. 


MEDICINES     THEIE     USES     AND     MODE 
OE     ADMINISTRATION, 

INCLUDING    A    COMPLETE    CONSPECTUS    OF    THE    THREE   BRITISH 

PHARMACOPEIAS,    AN   ACCOUNT   OF   ALL   THE    NEW 

REMEDIES,    AND   AN   APPENDIX    OF 

FORMUL-S. 


Second  Edition,  8vo.   14s. 


>^/^<y    /-  ^^-  x>-' 


05- • 


CLINICAL    LECTURES 


PRACTICE   OF  MEDICINE. 


ROBERT  L   GRAVES,   M.D.,   M.R.I.A., 

HONORARY    AND   CORRESPONDING    MBMBKIt    OK    THE    ROYAL  MBOICAL    SOCIETY    Ol-'    BERLIN, 

OF    THE   IMPERIAL    MEDICAL    SOCIETY    OF    VIENNA, 

AND  OF  THE  MEDICO-CUIRDRGICAL   SOCIETIES  OP  HAMBURGH,  TDBINGEN,  BRUGES,  MONTREAL,  KTC. 

FORMERLY   PHYSICIAN   TO   THE   MKATH    HOSPITAL   AND    COUNTY    OF    DUBLIN    INFIRMARY, 

LATE   PROFKSSOR   OF 

THE   INSTITUTES   OP   MEDICINE    IN    THE   SCHOOL    OF    PHYSIC    OP    IRKLAND, 

AND   ONE   OP   THE   PRESIDENTS    OP    THK   PATHOLOGICAL    SOCIETY    OF    DUBLIN. 


SECOND   EDITION. 

EDITED    BY 


J.  MOOEE  NELIGAN,  M.D,  M.R.I.A, 

PHYSICIAN    TO     JERTIS-STREET    HOSPITAL,   LECTURER     ON     THE     PRACTICE    OF    MKOICISE,     IX     Till 
DUBLIN     SCHOOL     OP     MEDICINE,     ETC. 


IN  TWO  VOLUMES. 


VOL.  I. 


DUBLIN ;  FANNIN  AND  CO. 

BOOKSELLERS   TO    THE    ROYAL    COLLEGE   OP    SURGEONS    IN    IRELAND. 

LONDON :   LONGMAN  AND  CO. 
EDINBURGH:  MACLACHLAN,  STEWART  AND  CO. 

MDCCCXLVIII. 


GOODWIN,   SON,   AND   NETHERCOTT,   PRINTERS, 
MARLBOROUGH-STREET. 


TO    THE      . 
RIGHT  HONORABLE  WILLIAM,  EARL  OF  ROSSE,  K.P., 

PRESIDENT    OF    THE    ROYAL   SOCIETY. 

THIS,  THE  SECOND  EDITION  OF  A  TREATISE 

ON 

CLINICAL  MEDICINE, 

IS  RESPECTFULLY  DEDICATED  BY  HIS  FRIEND, 

THE  AUTHOE. 


PREFACE. 


Having,  at  the  request  of  Dr.  Graves,  undertaken  to  edit  the  present 
Edition  of  his  Work  on  Clinical  Medicine,  my  chief  aim  has  been  to 
improve  its  truly  practical  character,  and  thus  render  it  if  possible  more 
useful  to  the  profession.  With  this  view  I  have  altered  and  re-arranged 
the  Contents,  classifying  the  various  diseases  and  subjects  treated  of, 
and  throwing  the  entire  into  the  more  suitable  form  of  Lectures.  This, 
so  far  as  related  to  the  Second  Part, — which  in  the  first  Edition  con- 
sisted of  miscellaneous  essays,  I  found  but  little  difficulty  in  doing ; 
for  the  author  having  been  always  in  the  habit  of  dictating  to  a  short- 
hand writer,  his  style  naturally  assumed  a  colloquial  character,  and 
therefore  required  but  very  little  alteration  to  reduce  it  to  that  of  a 
Lecture. 

With  this  same  object  in  view,  whatever  alterations  or  additions  I 
have  myself  made,  I  have  incorporated  with  the  text ;  knowing  practi- 
cally the  great  inconvenience  and  distraction  of  mind  to  the  reader, 
which  editorial  notes  or  matter  inserted  between  brackets  produce. 
Moreover,  I  have  been  differently  circumstanced  from  most  other 
editors,  having  had  all  through  the  zealous  co-operation  of  the  author 
and  his  approval  of  the  alterations  and  additions  made. 


Vm  PREFACE. 

The  reader  will  perceive  that  I  have  introduced  into  this  Edition 
several  of  the  author's  essays  which  were  omitted  from  the  first :  of  these 
I  wish  to  call  especial  attention  to  his  observations  on  two  subjects — 
the  Pulse  and  Cholera.  The  greater  part  of  the  former,  which  now 
constitutes  the  fourth  lecture,  was  originally  published  in  the  Dublin 
Hospital  Eeports,  nearly  five  and  twenty  years  since,  and  contains  an 
account  of  the  first  accurate  experiments  which  were  made  as  to  the 
effects  of  posture  on  the  frequency  of  the  pulse ; — an  inquiry  which  has 
been  since  then  carefully  investigated  by  Knox,  Guy  and  others,  with 
the  effect  of  stamping  with  correctness  the  original  observations  of  Dr. 
Graves,  and  proving  their  practical  value. 

The  subject  of  the  Cholera  is  just  at  present  an  all-important  one, 
when  this  pestilence  is  ravaging  a  great  portion  of  the  globe,  and  those 
countries  which  have  been  once  and  but  once  before  afflicted  with  it, 
are  again  threatened  with  a  visitation.  Shortly  after  the  cessation  of 
the  previous  epidemic,  Dr.  Graves  read  an  essay  before  the  College  of 
Physicians  on  its  origin  and  progress,  chiefly  with  the  view  of  proving 
its  contagious  character ;  this  essay  which  was  published  at  the  time, 
in.  the  Dublin  Journal  of  Medical  Science,  is  now  remodelled,  and  a 
short  history  of  the  present  epidemic  as  far  as  it  had  advanced  at  the 
time  those  lectures  were  going  through  the  press,  added. 

The  lectures  on  Pever  which  constitute  so  large  and  so  valuable  a 
portion  of  the  first  Volume  will  be  found  to  be  much  altered  as  regards 
arrangement ;  and  the  causes  and  mode  of  diffusion  of  the  late  epidemic 
with  which  this  country  was  visited,  have  been  noticed. 

Although  many  years  have  elapsed  since  several  of  the  author's  views 
on  the  physiology,  pathology,  and  treatment  of  diseases  were  first  pub- 
lished, and  the  science  of  medicine  has  been  since  extraordinarily 
advanced  by  the  aid  of  the  Chemist  and  the  Histologist,  but  few 
alterations  or  omissions  have  been  required  to  adapt  them  to  the 
present  state  of  knowledge.     Indeed  it  is  singular  how  many  of  his 


PREFACE.  ix 

observations,  which,  when  first  promulgated,  were  from  their  novelty 
either  doubtingly  received  or  altogether  rejected,  have  been  corroborated 
by  the  investigations  of  more  recent  inquirers.  Of  these  I  would  par- 
ticularly notice  his  views  "  on  the  Capillary  Circulation,  and  on  the 
Doctrines  of  Inflammation,"  confirmed  by  the  most  recent  microscopical 
investigations ;  "  on  the  Circulation  of  the  Blood  within  the  Cranium," 
confirmed  by  Dr.  Burrowes'  experiments ;  "  on  the  Pathology  of  Para- 
lysis," so  remarkably  in  accordance  with  the  Cerebro-spinal  Eeflex 
Theory ;  ''  on  the  Pathology  of  Tubercle ;"  and  "  on  the  Nature  of  the 
Acid  in  the  Human  Stomach." 

In  conclusion,  I  have  only  to  add,  that  these  Volumes  as  now  pre- 
sented to  the  reader,  contain  the  results  of  Dr.  Graves*  additional 
experience  during  the  five  years  which  have  elapsed  since  the  first 
Edition  was  published. 

J.    MOORE    NELIGAN. 

1 6,  Leeson-street,  Stephens  Greeiij 
Dublin^  September,  1848. 


CONTENTS. 


TO    THE 
RIGHT  HONORABLE  WILLIAM,  EARL  OF  ROSSE,  K.P., 

PRESIDENT    OF    THE    ROYAL    SOCIETY. 

THIS,  THE  SECOND  EDITION  OF  A  TREATISE 

ON 

CLINICAL    MEDICINE. 

IS    RESPECTFULLY    DEDICATED    BY    HIS    FRIEND, 

THE    AUTHOR. 


AUTHOR^S    PEEFACE. 


This  Work  first  appeared  in  1843,  and  its  publisher  informed  me  last 
year,  the  sale  had  been  so  rapid,  that  he  expected  the  whole  Edition 
would  be  soon  disposed  of.  The  event  more  than  justified  his  antici- 
pations, and  consequently  he  requested  me  to  prepare  a  Second  Edition 
for  the  press,  a  request  I  felt  bound  to  comply  with,  particularly  as  I 
was  conscious  that  much  might  be  done  to  render  the  work  more  de- 
serving of  the  approbation  which  my  brethren  and  colleagues  in  all  parts 
of  the  world,  had  so  kindly,  and  to  me  so  unexpectedly,  bestowed  on  it. 

On  revising  the  Yolume  as  before  printed,  I  detected  so  many 
faults  and  errors,  that  I  at  once  resolved  to  remodel  the  whole,  and 
accordingly  I  applied  myself  to  the  accomplishment  of  this  object, 
with  a  sincere  desire  to  render  my  Clinical  Medicine  still  more  useful 
to  the  profession.  I  soon  found,  however,  that  my  task  was  a  very 
difficult  one.  The  original  Work  contained  so  much  which  a  maturer 
reflection  and  experience  disapproved  of,  that  the  sections  to  be  omitted 
soon  swelled  to  a  formidable  bulk,  while  on  the  other  hand,  a  closer 
review  of  the  matters  discussed  suggested  the  necessity  of  inserting 
many  lectures  that  had  been  formerly  left  out. 


Xll  PREFACE. 

The  occupations  of  a  laborious  profession  so  encroached  on  my  time, 
that  I  found  my  plans  could  not  be  executed,  without  associating 
myself  with  some  other  physician,  in  whose  industry,  learning  and 
ability  I  reposed  confidence.  Having  been  fortunate  enough  to  secure 
the  co-operation  of  Dr.  Neligan,  I  felt  certain  that  the  result  would 
be  satisfactory,  and  I  placed  in  his  hands  the  numerous  cases  I  had 
collected  from  my  own  practice,  and  the  various  extracts  I  had  made 
from  books  since  the  publication  of  the  first  Edition.  To  these 
materials,  Dr.  Neligan  made  many  and  important  additions,  and  he 
has  bestowed  so  much  labour  on  the  two  Yolumes  now  submitted  to 
the  profession  and  the  public,  that  I  feel  confident  this  Edition  will 
be  found  a  great   improvement   on   the  former. 

ROBEET    J.    GRAVES. 

Merrion-square, 
1 5th  September,  1848. 


CONTENTS   OF   THE   FIRST  VOLUME. 


LECTURE  I. 


CLINICAL  INSTRUCTION— Objects  of  Hospital  Attendance— Importance  of 
studying  Chronic  Diseases — Edinburgh  Clinic — French  Clinic — German  method 
of  giving  Clinical  Instruction — Its  superiority — Plan  adopted  by  the  Author — 
Defective  system  of  instruction  required  by  the  London  University. p.  1 


LECTURE  II. 

Utility  of  German  method  of  Clinical  Instruction— Requisites  from  the  Students — 
Preliminary  Education — Age  for  commencing  the  study  of  Medicine — The  study 
of  Botany — Botanical  nomenclature — The  study  of  Chemistry — Inconvenience 
arising  from  changing  the  names  of  medicines — The  progress  of  Physiology  and 
Pathology  in  some  instances  retarded  by  the  researches  of  Chemists — Liebig's 
theories  of  Poisoning  and  Contagion  refuted — Liebig's  theories  of  Heat  disproved 
— Facts  wholly  inconsistent  with  his  views — Great  responsibility  of  a  teacher  of 
Clinical  Medicine  in  Great  Britain  and  Ireland — The  profession  of  Medicine, 

p.  14 

LECTURE  III. 

The  proper  mode  of  studying  Physiology  and  Morbid  Anatomy — The  study  of  Phy- 
siology— The  connexion  of  Morbid  Anatomy  with  Practical  Medicine — Errors  of 
Nosologists — The  utility  of  Morbid  Anatomy — The  difficulties  attending  its 
study — How  to  be  avoided — The  Dublin  Pathological  Society — Irish  medical 
literature p.  34 


LECTURE  IV. 

THE  PULSE — Effects  of  posture  on  the  frequency  of  the  Pulse — Difference  in 
different  positions  of  the  body  in  healthy  persons — The  Cerebral  Circulation — 
Effect  of  the  inverted  posture  on  the  Pulse — Effects  of  change  of  posture  on  the 
Pulse  in  disease— In  Hypertrophy  of  the  heart  with  dilatation — Results  of  nu- 
merous observations — Relation  which  the  Pulse  and  Respiration  bear  to  each 
other — A  Dicrotous  Pulse  in  fever — In  hemorrhages — Effects  of  digitalis  on  the 
Pulse — The  jiosition  of  the  egg  during  Incubation p.  45 


XIV  CONTENTS. 


LECTURE  V. 


INFLAMMATION — The  general  laws  of  Inflammation — Opinions  of  various  Phy- 
siologists— of  Dr.  Marshall  Hall — Refutation  of  his  views — The  circulation  of 
the  blood — Minute  blood  vessels — Capillary  circulation — Forces  by  means  of 
which  the  Circulation  of  the  Blood  is  accomplished — The  Vascular  System  in  the 
Foetus — The  circulation  in  the  Impregnated  "Womb — Dr.  Houston's  case  of  an 
Acardiac  Foetus — A  proof  of  the  independence  of  the  capillary  circulation — Dila- 
tation of  Arteries  and  Veins  in  inflamed  parts,  not  passive — Dr.  Williams'  views 
refuted — Dr.  Weatherhead's  conclusions — Miiller's  hypothesis  on  the  motion  of 
the  blood  in  the  Capillaries  untenable — Increase  of  size  in  the  Arteries— Proofs 
of  the  power  which  the  Capillaries  possess  of  drawing  Blood  to  themselves,  p.  52 

LECTURE  VI. 

Inflammation  continued — Proofs  of  the  capillary  power  drawn  from  the  Vegetable 

Kingdom Hales  and  Dutrochet's  experiment — The  Circulation  of  some  of  the 

lower  tribes  of  Animals — ^Dr.  Hastings'  and  Dr.  Philip's  views  as  to  the  state  of 
the  Capillaries  in  Inflammation — Case  of  deficient  circulation  in  the  legs — Dr. 
Carpenter's  opinions — Dr.  Holland's  views — ^Extract  from  Adelon's  Physiology 
on  the  Capillary  Circulation — Concluding  remarks  on  Inflammation p,  71 

LECTURE  VII. 

FEVER — Typhus  fever  endemic  in  Ireland — Dependant  on  some  general  Atmos- 
pheric Change — Not  of  Malarious  origin — Eflects  of  cultivation  and  drainage  on 
health — Mr.  Chadwick's  investigations — No  notable  diminution  of  fever  in  Ireland 
to  be  expected  from  Drainage,  improved  habits  of  Cleanliness  or  increased  Com- 
forts— ^Efiects  of  the  weather  on  the  Public  Health — Fatality  of  fever  in  Ireland 
— Dr.  Cowan  on  the  frequency  of  Fever  in  Britain — On  Epidemics  among  Cattle 
simultaneous  with  Human  Epidemics — Epidemic  of  1847 — Its  causes — Connexion 
between  Famine  and  Fever — Dr.  Lalor's  observations — Over-crowding  as  a  cause 
of  Fever — The  Work-houses — Dr.  Dillon's  letter — Fever  in  Cork — Efiects  of 
sudden  change  in  Diet — Proofs  of  the  Contagiousness  of  Typhus  Fever — Fever  of 
the  American  Emigrants  in  1847 — Outbreak  of  fever  in  Galway  gaol p.  82 

LECTURE  VIII. 

General  Observations  on  Fever — How  the  contagion  of  Fever  influences  the  system 
— Diff'erent  theories  of  Fever — Cheyne  and  Barker  on  the  epidemic  of  1817-18 — 
The  Author's  theory  of  Fever — Dr.  Christison's  views  of  Fever — Pathology  of 
Typhus  Fever — Classification  of  Irish  fever — Contagion  of  fever — Dr.  Perry's 
observations  on — Petechial  fever  not  epidemic  in  Ireland p .  1 00 

LECTURE  IX. 

General  Treatment  of  Fever — Epidemic  of  1836-37 — Interest  and  importance  of 

fever  as  a  disease The  treatment  of  fever  not  a  matter  of  indifierence — Points 

to  be  chiefly  attended  to — Necessity  for  a  Nurse — ^Fever  patients  should  be  fre- 
quently visited — General  observations — Diet — Patients  not  to  be  allowed  to  die 
of  Starvation — Directions  for  the  administration  of  food — Drinks — Green  tea  as 
an  expergefacient — ^Flagellation — Injurious  efiects  of  the  ad  libitum  use  of  Soda- 
or  Selters- water,  and  efiervescing  draughts  in  Fever p.  Ill 


CONTENTS. 


LECTURE  X. 


XV 


General  Treatment  of  Fever  continued — Importance  of  a  proper  Regimen Inju- 
rious effects  of  drastic  Purgatives  in  the  early  and  middle  stages  of  Typhus 
Fever — Tympanitis — Uses  of  air  in  the  intestines — Treatment  of  tympanitis  by 
oil  of  turpentine,  and  by  acetate  of  lead — Beneficial  effects  of  oil  of  turpentine  in 
intestinal  hemorrhages — Hiccup — Hemorrhage  from  the  bowels  in  fever. ..p.  127 


LECTURE  XI. 

General  Treatment  of  Fever  continued — Emetics  may  cut  short  the  disease  at  its 
commencement — Directions  for  tlieir  administration — The  use  and  abuse  of  Pur- 
gatives— Absurdity  of  the  idea  of  curing  fever  by  active  purging — Symptoms 

which  indicate  their  employment — .Their  mode  of  administration Bleeding 

The  influence  of  in  checking  fever — Circumstances  which  indicate  its  employ- 
ment— Never  to  be  used  when  maculae  are  present — Leeches  and  Cupping  in 
local  inflammations p.  137 


LECTURE  XII. 

General  Treatment  of  Fever  continued — Blisters — Answer  a  twofold  purpose,  sti- 
mulants or  derivatives — Mode  of  application  where  stimulant  effect  is  required — 
Cerebral  symptoms  in  fever  should  be  always  anticipated — Two  classes  of  symp- 
toms which  indicate  the  approach  of  engagement  of  the  Head — Use  of  blisters  in 
both — The  state  of  the  respiratory  function  in  connection  with  Cerebral  Excite- 
ment— State  of  the  Pupils  during  Sleep — Application  of  flying  blisters  as  ener- 
getic stimulants — Illustration — Blisters  and  tartar-emetic  ointment  to  the  shaven 
scalp — Blisters  in  the  Pulmonary  Affections  of  fever — Mode  of  dressing  blisters — 
Peculiar  habits  and  Idiosyncrasies  of  families p.   149 


LECTURE  XIII. 

General  Treatment  of  Fever  continued — The  application  of  Cold  to  the  Head — Cold 
Affusion  as  practised  at  the  Charite  Krankenhaus  at  Berlin — Imperfect  mode 
in  which  Cold  Lotions  are  ordinarily  applied  to  the  head  in  fever — Advantages  of 
Warm  Fomentations — Use  of  Mercury  in  fever — Mercurialisation,  not  a  pre- 
ventive of  the  contagion  of  typhus — Illustration  of  the  treatment  of  Delirium 
in  fever — Mode  of  administering  Tartar  Emetic — State  of  the  cerebro-spinal 
system  in  Maculated  Typhus — Subsultus  tendinum — Vomiting  and  Diarrhoea  in 
the  beginning  of  fever — Scrofulous  secondary  fever p.  162 


LECTURE  XIV. 

Head  Symptoms  in  Fever — Dependant  on  opposite  conditions  of  the  cerebral  circu- 
lation— Cerebral  symptoms  must  be  always  closely  watched — Treatment  of — 
Majority  of  fatal  cases  in  this  country  rendered  so  by  the  supervention  of  Cere- 
bral Symptoms — They  are  therefore  to  be  checked  as  early  as  possible — Illustra- 
tions— Analogous  symptoms  occur  under  opposite  conditions  of  the  brain — Dr. 
Wilson  on  the  nature  of  Coup  de  Soleil — Case  illustrating  the  necessity  of 
repeatedly  visiting  a  fever  patient — Use  of  Turpentine  where  symptoms  of  ner- 
vous irritation  exist — Combination  of  Tartar  Emetic,  Opium,  Musk,  and  Cam- 
phor in  eruptive  typhus  with  alarming  symptoms p.  1 73 


XVI  CONTENTS. 

LECTURE  XV. 

Fever  continued — Bed  sores,  their  prevention  and  treatment — Use  of  a  second  bed 
in  the  patient's  apartment — Contagion  of  the  Epidemic  of  1834 — Mercury  not  a 
prophylactic  of  fever — Illustration — Symptoms  of  inflammation  or  congestion  of 
the  brain  in  the  course  of  fever — Rigors,  Ear-ache,  &c — Treatment  of— Irritabi- 
lity of  the  Stomach  without  epigastric  tenderness  is  in  all  febrile  complaints 
symptomatic  of  Congestion  of  the  Brain — Seat  of  the  Swellings  of  the  Neck 
which  occur  in  the  latter  stages  of  fever — Do  not  arise  from  inflammation  of  the 
Parotid  or  Submaxillary  Gland — Illustrated  by  cases — Mumps p.  186 

LECTURE  XVI. 

Fever  continued — Tartar  Emetic  in  the  treatment  of  the  cerebral  excitement  of 
fever — Maculated  typhus  with  cerebral  symptoms — ^Proofs  of  the  author's  ori- 
ginality as  to  the  administration  of  tartar  emetic  in  such  cases — Tartar  Emetic 
combined  with  Opium  in  fever — Cases  illustrating  its  efiects — Analogy  between 
cerebral  symptoms  in  fever  and  delirium  tremens — Difference  in  the  indications 
as  to  the  use  of  antiphlogistic  measures,  where  cerebral  symptoms  occur  at  the 
Commencement,  and  at  the  Termination  of  fever p.  197 

LECTURE  XVII. 

Fever  continued — Mode  in  which  the  combination  of  Tartar  Emetic  with  Opium 
acts — The  stage  of  fever  in  which  it  proves  most  useful — No  relief  to  be  expected 
from  perspirations  in  the  commencement  of  fever — Cases  illustrating  the  eflScacy 
of  tartar  emetic  and  opium  in  fever,  and  the  form  of  their  administration — Small 
quantity  of  Laudanum  which  produces  sleep  when  thus  combined — Other  symp- 
toms produced  by  Functional  or  Organic  Lesions  of  various  Organs  may  prevent 
this  combination  from  producing  the  desired  result — Relative  proportions  of 
Tartar  Emetic  and  Laudanum  to  be  used p.  207 

LECTURE  XVIII. 

Fever  continued — Maculated  fever  of  1834-35 — Existence  of  general  tenderness 
over  the  surface  of  the  body  in  fever — Combination  of  primary  nervous  excite- 
ment with  secondary  cerebral  congestion — Some  additional  remarks  on  the 
Tartar  Emetic  and  Opium  plan  of  treatment — Tartar  emetic  in  large  doses  in 
Malignant  Fever — Observations  of  Dr.  Marryatt  of  Bristol  published  in  1788 — 
Illustrative  cases — Hippocrates  on  the  danger  of  Convulsions  in  fever — Doses  of 
medicines  must  be  pronounced  large  or  small  only  according  to  their  effects — Dr. 
Kilgour  and  Dr.  Hudson  on  the  author's  plan  of  using  tartar  emetic  in  fever. 

p.  229 

LECTURE  XIX. 

Fever  continued — The  administration  of  Wine — Dr.  Stokes'  views — Author's  opinion 
that  the  debilitated  state  of  the  heart  in  fever  depends  on  a  general  prostration 
of  the  nervous  energy  and  not  on  softening — Symptoms  which  indicate  the 
employment  of  Wine  and  Opium  in  fever — Sequelae  of  fever — Delirium — Coming 
on  Avithout  any  premonitory  symptom— Tartar  emetic  combined  with  Musk  and 
Opium  in — Supervention  of  other  diseases  in  fever — Swelled  leg  simulating 
Phlegmasia  dolens  and  Phlebitis — Hemorrhage  from  the  bowels  in  fever... p.  249 


CONTENTS.  Xvii 

LECTURE  XX. 

Fever  continued — Nervous  fever — Critical  days  in  fever — Prognosis  in  fever  must 
be  in  every  case  extremely  cautious — Illustration — Prescriptions  in  fever — Ne- 
cessity for  employing  medicines  of  an  expectant  and  temporising  character 

Formulae  for  such — Inflammation  of  the  Mammae  in  fever — Causes  and  treat- 
ment of— Change  in  opinion  with  respect  to  fever — Concluding  remarks  on  Fever. 

p.  268 
LECTURE  XXI. 

YELLOW  FEVER  of  the  British  Islands — Louis's  account  of  the  Gibraltar  Epi- 
demic— Compared  with  the  Irish  Epidemic  of  1826 — Dr.  Stokes'  and  the 
Author's  account  of — Illustrative  Cases  from  their  report — Morbid  appearances 
of  the  stomach  in  Yellow  fever — Nature  of  the  disease — A  variety  of  Continued 
fever— Summary  of  symptoms  in  the  Dublin  Epidemic — The  Dublin  fever  of 
1826-7  contrasted  with  Louis'  description — The  Scotch  Epidemic  of  1843-44 — 
Isolated  cases  of  Yellow  fever  since  seen  by  the  Author p.  280 

LECTURE  XXII. 

SCARLATINA— Epidemic  of  1801-2-3-4— Original  mildness  of  the  disease- 
Change  in  its  character — Dr.  Autenreith's  observations  on  the  causes  capable  of 
modifying  diseases — The  Inflammatory  constitution  of  disease  recently  replaced 
by  a  Typhous  type — Proved  by  the  recent  Epidemics  of  Influenza,  Cholera, 
and  Fever — Scarlatina  continued  to  be  of  a  mild  type  until  1831 — Forms  which 
the  disease  when  violent  assumed — Eflects  of  depletion  in  Epidemic  of  1834 — 
Mr.  O'Ferrall's  communication p.  303 

LECTURE  XXIII. 

Scarlatina  continued — Communications  from  Provincial  Practitioners  as  to  the 
difi'usion  and  type  of  the  disease  in  the  country  districts  of  Ireland — No  Geolo- 
gical or  Physical  peculiarities  in  the  various  localities  to  account  for  the  differ- 
ence in  the  reports — The  mild  form  co-existed  in  Dublin  with  the  most  virulent 
— Dr.  Osbrey's  communication p.  324 

LECTURE  XXIV. 

Scarlatina  continued — Absence  of  eruption  in — Illustrative  cases — Aphthous  ulce- 
ration of  the  Anus  in — Hemorrhage  from  the  nose  in — Hemorrhage  from  the  ear 
in — Difi"use  inflammation  of  the  neck  after — Scarlatina  without  eruption  capable 
of  communicating  infection — A  constitutional  afiection  may  display  its  existence 
by  only  one  or  two  of  the  numerous  symptoms  which  usually  accompany  it — 
Dropsy  after  scarlatina — Treatment  of  dropsy  with  Albuminous  urine p.  338 

LECTURE  XXV. 

INTERMITTENT  FEVER— Quartan  ague,  defined— Reasons  why  twelve  hours 
should  be  the  unit  employed  in  calculating  intervals  between  the  accession  of  one 
attack  and  the  accession  of  the  next  in  ague — Illustrations  from  the  occurrence 
of  crises  in  fever — Effects  of  Sulphate  of  Quina  and  of  Arsenic  in  ague — An  affec- 
tion chiefly  of  the  nervous  system — A  form  of  ague  in  which  the  attacks  return 
every  seventh  day — Tertiana  Soporosa — Ague-cake — Congestion  of  internal 
organs  during  paroxysms — Diseases  which  simulate  ague — Treatment — The 
Malarious  fever  of  Africa — Capability  of  Negroes  of  withstanding  the  deleterious 
exhalations  by  which  it  is  produced — Practical  deductions  therefrom p.  353 


XVlll  CONTENTS. 

LECTURE  XXVI. 

Intermittent  fever,  continued — Relapse  periods  of — Law  by  which  they  are  regu- 
lated applies  to  the  free  intervals  between  the  fits — Case  in  illustration — Ob- 
stinate ague  even  where  accompanied  by  various  complications  may  be  cured  by 
Quina  alone —Best  method  of  administering  it — Table  showing  the  quantity 
taken  in  one  case p.  369 


LECTURE  XXVII. 

CHOLERA — Origin  and  progress — ^Difference  in  the  course  of  Epidemic  Cholera 
and  Epidemic  Influenza — March  of  Cholera  from  India — Unknown  in  Europe 
before  the  present  century — Cholera  Epidemic  of  1817  in  India — Spread  of  the 
disease  along  the  rivers  and  routes  most  frequented  by  travellers — It  never  tra- 
velled the  ocean  at  a  rate  exceeding  that  of  ships — Arrival  in  England — in 
Ireland p.  383 


LECTURE  XXVIII. 

Cholera  continued — Its  route  in  America — Probable  transmission  there  by  emigrant 
ships — Dr.  Jackson's  account  of  its  spread — Deductions  as  to  its  being  a  con- 
tagious disease — Epidemic  of  1842  in  India — Spread  to  Europe  in  1847 — Its 
progress  in  1848 — Treatment  of  Cholera — Acetate  of  Lead  and  Opium  in — 
Treatment  by  Calomel — Mode  of  administering  acetate  of  lead  in  Cholera — The 
recent  proofs  of  the  efficacy  of  this  remedy  in  Cholera  in  India p,  402 


LECTURE  XXIX. 

INFLUENZA — ^Difference  in  mode  of  spreading  between  it  and  Cholera — Influenza 
does  not  depend  on  mere  variations  of  temperature — Probably  depends  chiefly 
on  Telluric  Influence — Epidemics  of  Influenza  in  the  eighteenth  and  nineteenth 
centuries — Symptoms  of  the  disease  vary  in  different  individuals — Mortality 
from  in  Dublin  in  1837  and  1847 — Difference  in  the  characters  of  the  Epidemics 
of  1834,  1837,  and  1847 — Nature  and  symptoms  of  Influenza — Illustrative 
cases — Dr.  Greene's  report  of  the  Morbid  Appearances  in  fatal  cases — Treatment 

p.  422 

LECTURE  XXX. 

CONNEXION  BETWEEN  DISEASES  OF  DIFFERENT  ORGANS— Arth- 
ritis, Hepatitis,  and  Urticaria — Proofs  of  this  connexion  from  the  effects 
sometimes  produced  on  the  system  by  eating  fish — Venereal,  Periostitic  Inflam- 
mation, and  Hypertrophy  of  the  Liver — Cases  in  illustration — Rationale  of  in- 
termittent secretion  of  bile  by  the  liver — Consecutive  affection  of  the  Liver  in 
Morbus  Coxae — Curability  of  hepatic  affections  of  this  kind — Disease  of  Liver 
produced  by  immoderate  use  of  Mercury — Scarlatina  and  Disease  of  the  Liver — 
Connexion  between  disease  of  the  Heart  and  Hypertrophy  and  Disease  of  the 
Liver — Ague  and  Diseased  Liver — Connexion  between  Diseases  of  the  Spleen 
and  General  Diseases  affecting  the  system — Notices  of  by  Voight  and  Aretaeus 

p.  446 


CONTENTS.  xix 

LECTURE  XXXI. 

GOUT— Constitutional  Inflammation  in  general— Local  Inflammations  depending 
on  a  Constitutional  cause  sometimes  remarkably  Fugitive  and  Transient Gouty- 
pains  or  twitches — Gouty  tumours  of  the  face— Grinding  of  the  teeth  in  gouty 
habits — Functions  of  the  Dental  Nerves — Paralysis  of  these  nerves  has  never 
been  observed — Gouty  Neuralgia — Illustrative  Cases — Gouty  redness  of  the 
Nose — Premonitory  symptoms  of  an  attack  of  Gout  in  the  Extremities— Excep- 
tions to — Gouty  Bronchitis — Gouty  inflammation  of  the  Peripheral  nerves  may 
extend  to  the  Spinal  Marrow — Illustrations — Treatment — Concluding  Observa- 
tions p.  460 

LECTURE  XXXII. 

RHEUMATISM — Arthritic  Rheumatism — General  Observations  on  Treatment 

of— Sweating  in  the  Commencement  of  the  disease  an  Important  Symptom 

The  efiects  of  Mercury   when   applied  locally — Mercury  and  Hydriodate  of 

Potash  in  Rheumatic  Fever — Illustrative  Cases — Chronic  Rheumatism A  very 

intractable  disease — Treatment — Sciatica  and  Lumbago — General  Treatment — 
Cupping — Hydriodate  of  Potash — Illustrative  Cases — Treatment  of  Chronic 
Sciatica p.  486 

LECTURE  XXXIII. 

PATHOLOGY  OF  NERVOUS  DISEASES The  Author's  New  Views— An 

Injury  of  the  Extremities  or  Circumferential  parts  of  the  Nerves  may  cause 
Paralysis — Illustrative  Cases — Effects  of  Cold  on  the  Extremities The  Epide- 
mic de  Paris  an  example  of  disease  of  the  Nervous  System  commencing  in  the 
Extremities — ^Both  Hemiplegia  and  Paraplegia  may  commence  in  the  Extremities 
— The  former  rarely — Illustration  of  the  Author's  Views  from  the  Paralysis 
caused  by  the  Poison  of  Lead — Spinal  Neuralgia  of  Chronic  Complaints  and 
Hysterical  Affections — Additional  cases  in  illustration  of  the  Author's  Views — 
Paralysis  of  the  Insane p.  500 

LECTURE  XXXIV. 

APOPLEXY — Symptoms  of  Cerebral  Disease  and  Morbid  Appearances  do  not 
always  agree — Diagnosis  therefore  difficult — Two  cases  of  Apoplexy  in  Illus- 
tration— General  Opinions  as  to  the  causes  of  Paralysis — The  Author's  experi- 
ence as  to  their  Truth — Cases  in  illustration — Causes  of  Hemiplegia — Mode  of 
explaining  the  occurrence  of  slight  Paralytic  Attacks — The  symptoms  indicative 
of  Ramollissement  of  the  Brain  not  to  be  always  relied  on — Knowledge  of  the 
Morbid  Anatomy  of  the  Brain,  how  far  useful — Case  of  Epilepsy  without  Or- 
ganic disease  of  the  Brain  or  Spinal  Marrow p.  513 

LECTURE  XXXV. 

DELIRIUM  TREMENS.— Case  of  Complicated  with  several  Inflammatory  Dis- 
eases— Causes  of  delirium  in  Acute  Bronchitis — Treatment  of  Delirium  Tre- 
mens— Complication  of  Delirium  Tremens  with  Acute  Rheumatism. — CHOREA 
— Obstinate  Case  of — Treatment  which  at  length  proved  successful— Effects  of 
water  poured  on  the  naked  skin — Treatment  of  Chorea  by  Sulphate  of  Zinc — 
Cases  of  Chorea  occurring  for  the  first  time  in  advanced  life.— EPILEPSY — 
Treatment  of  by  Sulphate  of  Zinc— Case  of  Epilepsy  depending  on  injury  to 
the  Bones  of  the  Cranium P-  529 


XX  CONTENTS. 


LECTURE  XXXVI. 


PARALYSIS — The  obscurer  varieties  of  Paraplegia — Their  production  by  Reflex 
Action — Exemplified  by  the  occurrence  of  Tetanus  from  injury,  and  of  Con- 
vulsions from  Intestinal  Worms  and  from  Cutaneous  Irritation — Spinal  Tender- 
ness in  Hysteria — Illustrative  Cases  of  Paraplegia — Mode  of  explaining  the 
Paraplegia  which  occurs  after  Inflammation  of  the  Bowels — Connexion  between 
Paraplegia  and  Disease  of  the  Kidneys — Observations  on  Mr.  Stanley's  cases  of 
Paraplegia — The  Priority  of  the  Author's  Views  on  the  Pathology  of  Paralysis 
asserted p.  543 

LECTURE  XXXVII. 

Paraplegia  continued — Dr.  Hutton's  case  of  Irritation  of  the  Urinary  Organs 
causing  Paraplegia — Paraplegia  occurring  in  the  course  of  Fever — Illustrative 
Cases — Explanation  of  the  cause  of— Paralysis  a  consequence  of  Erysipelas,  of 
Phlegmasia  Dolens  and  of  injury  to  one  of  the  Principal  Nerves  of  a  Limb — 
Paraplegia  produced  by  the  Action  of  Cold  on  the  Lower  Extremities — Illus- 
trative Case — Causes  of  this  form  of  Paraplegia — Diagnosis  between  it  and  Para- 
plegia dependant  on  Spinal  Disease — Prognosis  and  Treatment p.  554 

LECTURE  XXXVIII. 

VARIOUS  NEURALGIC  AFFECTIONS— Bell's  Paralysis—May  exist  indepen- 
dent of  Cerebral  Disease — Illustrative  Cases — Singular  Affection  of  the  muscles 
of  the  face  named  by  the  Author,  Bell's  Spasms  of  the  Portio  Dura — Neuralgic 
AflPection  of  the  Larynx — Loss  of  Speech  may  arise  from  apparently  trifling 
lesions — Case  of  Stammering  cured  by  Laryngitis — Pathology  and  Treatment 
of  Stammering — Neuralgia  of  the  Mammae — On  the  administration  of  Tonics — 
Neuralgia  of  the  Testicle — Cases  of  injury  to  the  Jaws  or  Dental  Nerves  simu- 
lating Tic  Douloureux — Infantile  Convulsions — Causes  and  Treatment  of — Indi- 
gestion a  special  cause — Caution  in  giving  Opium  to  Children — Myelitis... p.  568 


CLINICAL    LECTURES 


ON    THE 


PRACTICE    OF    MEDICINE. 


LECTCJEE   I. 


CLINICAL    INSTRUCTION. 


Gentlemen, — Before  we  commence  an  examination  of  the  cases  at 
present  in  the  medical  wards  of  this  hospital,  it  is  necessary  to  explain 
the  method  of  instruction  which  I  mean  to  adopt.  Employed  else- 
where in  learning  the  principles  that  constitute  the  basis  of  medical 
education,  you  ought  to  be  impressed  with  a  precise  notion  of  the 
peculiar  objects  and  utility  of  hospital  attendance.  You  come  here  to 
convert  theoretical  into  practical  knowledge ;  to  observe  the  symptoms 
of  diseases  previously  known  to  you  only  through  the  medium  of  books 
or  lectures ;  to  learn  the  art  of  recognising  these  symptoms,  and  of 
appreciating  their  relative  importance  and  value ;  to  study  their  con- 
nexion with  morbid  alterations  of  internal  organs;  and,  finally,  to 
become  acquainted  with  the  best  method  of  relieving  your  patients,  by 
the  application  of  appropriate  remedies. 

Such,  gentlemen,  are  the  objects  you  seek  in  coming  here ;  and  in 
proportion  to  the  number  and  importance  of  these  objects,  are  the 
degree  of  responsibility  attached  to  your  clinical  instructors,  and  of 
blame  to  yourselves,  should  the  opportunities  which  this  institution 
offers  for  your  benefit  be  neglected. 

vol.  1.  1 


2  CLINICAL    MEDICINE. 

The  other  branches  of  medical  education  may  be  cultivated  at 
different  times,  and  according  to  a  certain  order  of  succession_, — one 
period  of  your  studies  demanding  a  particular  application  to  anatomy, 
another  to  chemistry,  while  a  third  must  be  especially  devoted  to 
materia  medica.  With  the  observation  of  disease  it  is  otherwise. 
From  the  very  commencement,  the  student  ought  to  witness  the  pro- 
gress and  effects  of  sickness,  and  ought  to  persevere  in  the  daily  obser- 
vation of  disease  during  the  whole  period  of  his  studies. 

The  human  mind  is  so  constituted,  that  in  practical  knowledge  its 
improvement  must  be  gradual.  Some  become  masters  of  mathematics, 
and  of  other  abstract  sciences,  with  such  facility,  that  in  one  year  they 
outstrip  those  who  have  laboured  during  many.  It  is  so,  likewise,  in 
the  theoretical  parts  of  medicine;  but  the  very  notion  of  practical 
knowledge  implies  observation  of  nature  ;  nature  requires  time  fo  r  her 
operations  :  and  he  who  wishes  to  observe  their  development  will  in 
vain  endeavour  to  substitute  genius  or  industry  for  time.  Remember, 
therefore,  that  however  else  you  may  be  occupied — whatever  studies 
may  claim  the  remainder  of  your  time,  a  certain  portion  of  each  day 
should  be  devoted  to  attendance  at  an  hospital,  where  the  pupil  has  the 
advantage  of  receiving  instruction  from  some  experienced  practitioner. 
A  well-arranged,  and  sufficiently  extensive  hospital,  contains  every  thing 
that  can  be  desired  by  the  student ;  but,  unfortunately,  his  improvement 
is  seldom  proportioned  to  the  opportunities  he  enjoys.  Whence  this 
deficiency  ?  How  does  it  happen  that  many  attend  hospitals  day  after 
day,  and  year  after  year,  without  acquiring  much  practical  knowledge  ? 
This  may  be  attributed  to  want  of  ability  or  dihgence  on  the  part  of 
the  student,  or  to  an  injudicious  or  careless  method  of  teaching  on  the 
part  of  the  hospital  physician.  It  may  be  well  to  examine  more  in 
detail  the  errors  to  which  the  student  and  the  teacher  are  respectively 
most  exposed. 

A  great  number  of  students  seem  little,  if  at  all,  impressed  mth  the 
difficulty  of  becoming  good  practitioners ;  and  not  a  few  appear  to  be 
totally  destitute  of  any  prospective  anticipation  of  the  heavy,  the  awful 
responsibiUty  they  must  incur  when,  embarking  in  practice,  the  lives 
of  their  fellow- creatures  are  committed  to  their  charge.  It  is  by  per- 
sons of  this  description  that  the  earnest  attention,  and  permanent 
decorum,  which  ought  to  pervade  a  class  employed  in  visiting  the  sick, 
are  so  frequently  interrupted.  Young  men  of  the  character  to  which 
I  allude,  attend  or,  as  it  is  quaintly  enough  termed,  walk  the  hospitals 
very  regularly,  but  they  make  their  appearance  among  us  rather  as 
critics  than  as  learners  :  they  come,  not  to  listen  but  to  speak  ;  they 
consider  the  hospital  a  place  of  amusement  rather  than  of  instruction. 
I  am  happy  to  be  able  to  state  that  such  characters  are  not  very  nume- 


CLINICAL   INSTRUCTION.  3 

rous  here,  for  this  hospital  possesses  no  other  attractions,  confers  no 
special  qualification  beyond  the  knowledge  which  may  be  obtained 
within  its  walls."'*' 

Of  those  who  are  anxious  to  learn  their  profession,  a  great  number 
fail,  and  are  found  wanting  when  their  studies  are  finished ;  in  a  few, 
the  failure  may  be  traced  to  a  deficiency  of  intellectual  powers ;  but  in 
the  majority  it  is  owing  to  their  studies  being  erroneously  directed. 
Thus  I  have  known  many  who  have  displayed  a  taste  for  the  study  of 
the  progress  and  treatment  of  acute  diseases,  while  they  paid  but  little 
attention  to  complaints  of  a  chronic  nature.  This  predilection  is  not 
confined  to  students ;  professors  and  authors  in  general  seem  to  parti- 
cipate in  this  taste;  and,  consequently,  we  find  that  acute  diseases 
form  the  favourite  subjects  of  cHnical  lectures,  and  occupy  the  greatest 
portion  of  medical  literature — and  for  obvious  reasons;  for  if  the 
course  of  acute  diseases,  such  as  fever  and  the  phlegmasise,  be  com- 
pared with  that  of  chronic  maladies,  we  shall  find  that  the  former 
begin,  continue,  and  end  in  a  manner  comparatively  so  regular  and 
definite,  that  their  progress  can  often  be  accurately  predicted,  and  their 
terminations  foreseen, — a  circumstance  which  enables  us  not  only  to 
predict  the  event  with  confidence,  but  obtain,  by  the  well-timed  appli- 
cation of  active  remedies,  relief,  evidently  the  result  of  the  means  em- 
ployed, and,  consequently,  reflecting  credit  both  upon  the  physician 
and  the  art  of  medicine.  How  satisfactory  are  our  feelings  on  arresting 
the  progress  of  pneumonia  by  venesection,  or  tranquilUzing  the  mania 
of  delirium  trem-ens  by  means  of  opium  ! 

Far  different  is  the  case  with  chronic  diseases  :  in  their  commence- 
ment generally  obscure,  insidious,  and  irregular;  in  their  terminations 
necessarily  uncertain;  frequently  transferring  themselves,  as  it  were, 
from  one  part  of  the  system  to  another,  occasioning  unexpected  and 
anomalous  symptoms,  and  involving  in  their  destructive  course  almost 
every  tissue  of  the  body.  From  the  very  length  of  their  duration,  they 
are  also  more  liable  to  be  modified  by  new  physical  and  moral  influ- 
ences, affecting  either  the  mind  or  body ;  and  are,  in  a  word,  more 
closely  leagued  with  time,  the  parent  of  mortality.  In  the  treatment 
of  such  affections,  the  greatest  judgment  and  patience  are  requisite; 
there  is  here  no  room  for  the  application  of  heroic  remedies ;  nor  can 

*  Since  this  was  written,  the  Meath  Hospital  became  for  several  years  a  privileged 
hospital.  Latterly  this  premium  upon  idleness  has  been  again  withdrawn  from  us,  and 
I  most  heartily  rejoice  that  this  and  other  hospitals  have  ceased  to  form  a  sort  of  favoured 
oligarchy  to  the  exclusion  of  the  less  extensive  institutions  of  this  city  ;  'every  thing  like 
monopoly  tends  to  retard  the  advancement  of  science,  and  I  see  no  reason  why  an  hospital 
with  50  beds  should  be  inferior  to  one  with  100.  It  is  not  the  quantity  of  disease  a  teacher 
treats  which  renders  his  lesson  instructive  ;  his  diligence  and  accuracy  of  observation  are 
the  best  means  of  instructing  the  pupils. 


4  CLINICAL   MEDICINE. 

the  physician  expect,  from  his  most  persevering  exertions,  that  speedy 
benefit  by  which  he  acquires  eclat  in  acute  cases,  for  it  must  be  re- 
membered that  chronic  diseases  require  clironic  remedies. 

This  most  difficult  department  of  medicine  surely  claims  not  the 
least  portion  of  your  attention,  and  you  will  attach  more  importance  to 
this  subject  on  considering  that  a  knowledge  of  chronic  diseases  is 
essential  to  the  surgeon,  inasmuch  as  those  who  labour  under  them, 
remain  exposed  to  accidents  which  constitute  his  peculiar  province.^ 

Many  students  fail  from  another  cause :  instead  of  studying  the 
most  common,  and  on  that  account,  the  most  important  diseases,  they 
acquire  a  taste  for  observing  and  relating  singular  and  rare  cases,  as  if 
their  chief  object  was  to  obtain  a  store  of  curious  medical  information. 
Let  me  w^am  you  against  this  amusing,  but  comparatively  unprofitable 
employment  of  your  time.  Suffer  not  yourselves  to  be  misled  by  those 
who  prefer  the  gratification  of  an  idle  curiosity  to  the  laborious  inves- 
tigation of  ordinary  diseases. 

Students  should  aim  not  at  seeing  many  diseases  every  day,  not  at 
visiting  daily  numerous  cases ;  no,  their  object  should  be  constantly  to 
study  a  few  cases  with  diligence  and  attention ;  they  should  anxiously 
cultivate  the  habit  of  making  accurate  observations.  This  cannot  be 
done  at  once ;  this  habit  can  be  only  gradually  acquired.  It  is  never 
the  result  of  ability  alone;  it  never  fails  to  reward  the  labours  of 
patient  industry.  You  should  also  endeavour  to  render  your  observa- 
tions not  only  accurate  but  complete ;  you  should  follow,  when  it  is 
possible,  every  case  from  its  commencement  to  its  termination ;  for  the 
latter  often  affords  the  best  explanation  of  previous  symptoms,  and  the 
best  commentary  on  the  treatment.  Did  time  permit,  I  could  expose 
many  other  erroneous  practices  calculated  to  render  your  studies  com- 
paratively unprofitable;  but  I  must  turn  from  the  student  to  the 
teacher — from  the  errors  of  the  learner  to  the  imperfection  of  the  mode 
adopted  for  instructing  him. 

I  have  had  an  opportunity  of  observing  with  attention  three  different 
methods  of  conducting  clinical  instruction ;  the  first  is  that  practised 
in  Edinburgh  and  Dublin.  I  shall  select  that  of  Edinburgh  for  exam- 
ination, being  by  far  the  most  celebrated  of  the  British  schools  of 
physic,  and  much  resorted  to  even  by  foreigners  for  instruction.t  Two 
clinical  clerks,  one  for  the  male,  another  for  the  female  wards,  are 
selected  by  the  physician  from  among  the  senior  pupils ;  their  business 
is  to  write  an  accurate  history  of  the  cases,  to  report  the  effects  of 
medicines,  and  record  the  symptoms  which  may  have  occurred  since  the 

•  At  the  time  this  lecture  was  written,  the  absurd  idea  that  the  education  of  a  surgeon 
should  differ  from  that  of  physician,  had  not  been  altogether  abandoned. 
+  1  speak  of  Edinburgh  as  it  was  when  1  studied  there  in  1819. 


CLINICAL   INSTRUCTION.  5 

physician's  last  visit.  All  this  is  generally  done  with  fidelity  and  zeal. 
At  his  daily  visit  the  physician  stops  at  the  bed  of  each  patient,  and 
having  received  the  necessary  information  from  his  clerk,  he  examines 
the  patient,  interrogating  him  in  a  loud  voice,  while  the  clerk  repeats 
the  patient's  answer  in  a  tone  of  voice  equally  loud.  This  is  done  to 
enable  the  whole  audience  to  understand  what  is  going  on;  but 
indeed,  when  the  crowd  of  students  is  considerable,  it  is  no  easy  task ; 
it  requires  an  exertion  almost  stentorian  to  render  this  conversation 
between  the  physician  and  his  patient  audible  by  the  more  distant  mem- 
bers of  the  class ;  while  the  impossibility  of  seeing  the  patient,  obliges 
all  who  are  not  in  his  immediate  vicinity  to  trust  solely  to  their  ears 
for  information.^  This  information  is  not  indeed  neglected,  for  every 
word  so  attentively  listened  to,  and  heard  vdth  so  much  diiRculty,  is 
forthwith  registered  most  faithfully  in  each  student's  case-book ;  and 
afterwards  all  the  observations  the  professors  make  in  their  clinical 
lectures  are  taken  down  with  equal  care  and  fidelity. 

It  is  really  a  pity  to  find  so  much  labour  and  diligence  thrown  away ; 
for  it  is  evident  that  the  practice  of  medicine  cannot  be  thus  taught  or 
learned,  as  it  were  by  hearsay ;  and  it  is  consequently  to  be  feared,  that 
many  are  annually  dubbed  Doctors  at  Edinburgh,  who  have  been  scarcely 
ever  called  on  to  write  a  prescription.  The  chief  objection  to  this  mode 
of  teaching  is,  that  however  well  inclined  the  student  may  be,  he  is 
never  obliged  to  exercise  his  own  judgment  in  distinguishing  diseases, 
and  has  no  opportunity  of  trying  his  skill  in  their  cure ;  and,  conse- 
quently, at  the  end  of  his  studies  he  is  perhaps  well  grounded  in  the 
accessory  sciences — is  a  perfect  medical  logician — able  to  arrange  the 
names  of  diseases  in  their  classes,  orders,  and  different  subdivisions ; 
he  may  be  master  of  the  most  difficult  theories  of  modern  physiologists; 
he  may  have  heard,  seen,  and  if  a  member  of  the  Medical  Society,  he 
may  have  also  talked  a  great  deal ;  but  at  the  end  of  all  this  prepara- 
tion, what  is  he  when  he  becomes  a  full  Doctor  ? — a  practitioner  tvho 
has  never  practised  ! 

I  do  not  assert,  that  a  diHgent  student  may  not  obtain  a  good  deal  of 
knowledge  by  attending  one  or  several  clinical  courses  in  Edinburgh  ; 
no  doubt  he  will  gain  many  useful  general  ideas  concerning  the  nature 
and  treatment  of  disease ;  and  if  he  himself  examine  the  patient  after 
the  physician's  visit,  he  may  even  acquire  a  certain  degree  of  tact  in 
recognising  symptoms  and  appreciating  their  value.  This  method  of 
instruction  is  indeed,  vqy^  useful,  and  nothing  better  can  be  devised 

*  When  this  information  was  conveyed,  as  it  formerly  was  at  Sir  Patrick  Dun's 
Hospital,  in  Latin,  the  student  had  to  encounter  another  barrier  to  the  acquisition  of 
knowledge.  I  have  called  the  languaffe  L at m,  in  compliance  with  the  generally  re- 
ceived opinion  concerning  its  nature. 


6  CLINICAL   MEDICINE. 

for  a  beginner;  but  for  the  more  advanced  student  it  is  by  do  means 
sufficient,  nor  is  it  calculated  to  give  him  practical  experience,  without 
which  all  other  acquirements  are  of  no  avail.  I  say  it  does  not  give 
him  experience,  because  he  has  at  no  time  been  charged  with  the 
responsibility  of  investigating  a  case  for  himself  and  by  himself,  because 
at  no  time  has  he  been  called  on  to  make  a  diagnosis  unassisted  by 
others,  and  above  all,  because  he  has  never  been  obliged  to  act  upon 
that  diagnosis,  and  prescribe  the  method  of  treatment.  If  those  who 
have  been  thus  educated,  and  who  have  been  made  doctors  upon  so 
slender  a  foundation,  were  to  confess  the  truth,  we  should  be  presented 
with  a  picture  calculated  to  excite  dismay,  if  not  a  stronger  feeling. 
How  many  doubts  and  distracting  anxieties  attend  such  a  man  at  his 
first  patient^s  bedside  ?  If  the  disease  be  acute,  and  life  in  imminent 
danger,  and  if  he  shrink  under  this  sudden  and  unusual  load  of  re- 
sponsibility, he  gains  little  credit  for  professional  ability ;  if,  on  the 
contrary,  inexperienced  as  he  is,  he  assumes  that  decision  of  judgment, 
that  energy  of  practice — which  experience  alone  can  confer,  it  is  not 
improbable  that  the  result  may  be  stiU  more  disastrous. 

Gentlemen,  I  am  not  drawing  a  picture  from  my  imagination  alone ; 
I  have  had  occasion  too  often  to  shudder  at  the  original, — too  often'to 
deplore  the  sad  effects  resulting  from  the  well-meant  but  totally  mis- 
taken treatment  employed  by  young  men ;  and  often  have  I  regretted 
that,  under  the  present  system,  experience  is  only  to  be  acquired  at  a 
considerable  expense  of  human  life.  There  is,  indeed,  no  concealing 
the  truth,  the  melancholy  truth,  that  numbers  of  lives  are  annually 
lost  in  consequence  of  mal-treatment.  The  victims  selected  for  this 
sacrifice,  at  the  shrine  of  experience,  generally  belong  to  the  poorer 
classes  of  society,  and  their  immolation  is  never  long  delayed  when  a 
successful  candidate  for  a  dispensary  commences  the  discharge  of  his 
duty.  The  rich,  however,  do  not  always  escape ;  nor  is  the  possession 
of  wealth  in  every  instance  a  safeguard  against  the  blunders  of  inex- 
perience. 

This  charge  of  inexperience  is  not  necessarily  confined  to  the 
beginner ;  it  applies  equally  to  many  an  old  practitioner,  whose  errors 
have  grown,  and  have  increased  in  strength,  during  a  long  succession 
of  years ;  because,  from  a  defect  in  his  original  education — from  the 
absence  of  a  properly  directed  clinical  instruction,  he  commenced  prac- 
tice without  having  previously  acquired  the  power  or  the  habit  of  accu- 
rate observation ;  because  he  had  not  in  his  youth  been  taught  to  rea- 
son justly  upon  the  facts  presented  to  his  view ;  because,  not  having 
learned  in  the  beginning  to  think  accurately,  he  contracted  a  loose  and 
careless  mode  of  examining  the  progress  of  disease,  and  the  effects  of 
remedies  ;  and,  consequently,  the  lapse  of  time  has  had  no  other  effect 


CLINICAL    INSTRUCTION.  7 

Upon  his  errors,  than  that  of  rendering  them  more  inveterate.  Sucli  a 
man  has  generally  an  overweening  confidence  in  his  own  judgment ;  he 
never  detects  or  is  conscious  of  his  own  mistakes ;  and  instead  of  im- 
provement, years  bring  only  an  increased  attachment  to  his  opinions — 
a  deeper  bHndness  in  examining  the  results  of  his  own  practice ;  and 
do  not  such  persons  abound  in  every  branch  of  the  profession  ? — are 
there  not  general  practitioners,  are  there  not  physicians,  are  there  not 
surgeons,  are  there  not  apothecaries,  who  answer  to  this  description, 
and  who  nevertheless  are  cheerful  in  their  demeanour,  and  enjoy  a  good 
repute  among  their  chents  ?  Beheve  me,  gentlemen,  the  quacks  who 
cover  our  walls  with  their  advertisements,  vend  not  annually  to  the 
community  more  poison  than  is  distributed  according  to  the  prescrip- 
tions of  your  routine  and  licensed  practitioners  : — and  yet  the  science 
of  medicine  is  improving  daily,  and  treatises  on  the  practice  of  physic 
are  every  day  multiplying.  Why,  then,  is  society  so  infested  ?  Many 
circumstances  concur  to  produce  this  effect ;  but  the  most  influential  is 
undoubtedly  that  which  now  occupies  our  attention, — I  mean  a  system 
of  clinical  instruction  radically  wrong,  because  it  does  not  teach  the 
actual  practice  of  medicine.  Is  there  any  other  profession  or  art,  or 
even  trade,  in  which  any  but  a  madman  would  embark  unprovided  with 
a  store  of  practical  knowledge  ?  But  enough  of  this  unpleasing  sub- 
ject. Let  us  next  consider  what  systems  have  been  adopted  in  other 
countries,  with  a  view  of  judging  how  far  it  is  either  practicable  or 
expedient  to  introduce  them  into  this.^ 

In  Trance,  the  mode  of  conducting  clinical  instruction  is  very  similar 
to  that  which  we  have  already  described,  and  is  consequently  attended 
with  nearly  the  same  advantages  and  defects.  In  the  Prench  hospitals, 
however,  no  reports  are  dictated  to  the  clerks,  and  more  care  is  taken 
to  explain  the  symptoms  and  progress  of  each  case  at  the  bed-side  of 
the  patient :  in  fact,  these  explanations  answering  to  the  original  insti- 
tution and  design  of  clinical  lectures,  are  attended  with  many  important 
advantages,  and  are  well  worthy  of  imitation.  By  this  means  the 
trouble  and  uncertainty  of  a  circumstantial  and  detailed  description 
are  frequently  avoided  by  a  direct  reference  to  the  matter  to  be  de- 

*  As  truth  has  obliged  me  to  expose  a  fault,  which  the  Edinburgh  school  shares  in 
common  with  the  other  schools  of  Great  Britain,  I  am  bound  in  candour  to  acknowledge 
the  very  great  advantages  which  Edinburgh,  in  other  respects,  offers  to  students  ;  they 
there  find  themselves  surrounded  by  so  much  diligence,  enthusiasm,  and  zeal,  that  they 
can  scarcely  resist  the  impulse  of  improvement,  and  consequently  many  learn  there  to 
think  and  to  labour,  who  had  been  previously  careless  idlers.  That  such  was  the  case 
until  within  the  last  few  years,  is  undoubtedly  true ;  but  what  can  be  said  now,  in  favour 
of  a  university  in  which  the  Professor  of  Pathology  is  not  only  an  avowed  homeopathist, 
.but  has  written  a  booTc  with  the  view  of  proving  the  truths  and  promulgating  the  doc- 
trines of  that  ridiculous  sect  of  quacks, — and  the  Professor  of  Chemistry,  a  Professor  of 
Animal  Magnetism  ? 


8  CLINICAL   MEDICINE. 

scribed ;  and  the  interest  of  the  student  is  secured  by  a  very  slight 
exertion  on  the  part  of  his  instructor,  while  the  latter  owes  many  new 
ideas  to  the  degree  of  attention  which  he  is  thus  forced  to  give  each 
case.  It  is  true  that  the  duration  of  the  visit  is  thereby  increased ; 
and  in  Italy,  where  the  same  plan  is  pursued,  it  is  not  unusual  for 
Tommasini  to  expend,  in  the  morning,  more  than  two  hours  upon  eight 
or  ten  cases,  besides  the  time  devoted  in  the  evening  to  the  same  pur- 
pose. When  the  importance  of  the  subject  to  be  taught  is  so  great,  it 
is  wisely  judged  that  the  teachers  must  be  laborious ;  and  it  is  thought 
necessary  to  use  every  possible  means  to  convey  clear  ideas  concerning 
each  case  to  the  student.  His  attention  is  not  distracted  by  seeing  a 
great  number  of  cases  in  rapid  succession,  nor  (as  is  too  often  the  case 
in  the  hospitals  of  Dublin  and  London)  are  the  inquiries  dictated  by  a 
laudable  curiosity  on  the  part  of  the  student,  suppressed  by  a  forbidding 
demeanour  or  an  uncourteous  answer  from  his  teacher."^ 

Although  the  French  chnic  thus  presents  several  manifest  superiori- 
ties over  the  British,  yet  it  is  liable  to  the  chief  objection  already  urged 
against  the  latter — that  the  student  is  not  supplied  with  an  opportunity 
of  learning  the  actual  practice  of  his  profession.  I  am  by  no  means 
disposed  to  join  in  the  cant  of  humanity ;  yet  I  cannot  overlook  another 
disadvantage  to  this  mode  of  teaching.  I  cannot  help  feeling  that  it 
is  scarcely  justifiable  to  lecture  upon  a  patient^s  case  in  his  presence, 
and  in  his  native  language ;  that  it  is  cruel  to  explain,  (as  must,  when 
this  method  is  adopted,  be  often  done)  that  the  patient  is  labouring 
under  a  fatal  complaint.  During  such  a  lecture  I  have  often  watched 
the  worn  and  paUid  countenance  of  the  sufferer,  while  he  listened 
attentively  to  the  record"  of  his  past  and  present  sufferings,  and  I  have 
marked  the  settled  expression  of  despair  it  assumed  when  the  prognosis 
thus  tediously  ushered  in  was  too  clearly  announced.  It  is  cruel  to 
banish  from  the  sick  man's  bed  his  sole  remaining  comfort,  it  is  unmer- 
ciful to  scare  away  hope — his  only  consolation  during  hours  of  pain  and 
watching.  We  ought  never  to  allow  any  expression  to  escape  from  us 
which  could  possibly  add  the  terrors  of  apprehension  to  the  weight  of 
actual  suffering.  On  this  account,  while  we  borrow  the  useful  part  of 
their  system  from  the  Trench,  we  must  correct  so  glaring  a  defect  by 
making  use  of  the  Latin  language,  whenever  it  is  absolutely  necessary 


•  In  this  respect  our  hospital  physicians  and  surgeons  have  improved  much  since  1821. 
I  am  strongly  disposed  to  believe  that  the  improvement  was  not  owing  to  a  voluntary 
change,  but  to  a  certain  salutary  fear  of  public  castigation  from  the  weekly  medical 
press ;  much,  however,  remains  to  be  done,  for  the  influence  of  the  last  century  has 
not  yet  entirely  ceased,  and  there  are  those  still  lingering  among  us,  who  no  doubt 
regret  the  aristocratic  era,  when  an  impassable  gulf  lay  between  the  student  and  his 
teacher. 


CLINICAL    INSTRUCTION.  9 

to  make  any  observation  that  might  alarm  the  patient."^  One  of  the 
most  important  duties  of  a  surgeon^  or  physician,,  consists  in  the  prac- 
tice of  humanity  ;  and  it  is  very  doubtful  whether  the  student  does  not 
experience  as  much  difficulty  in  deriving  benefit,  not  so  much  from  the 
precept  as  the  example  of  his  seniors,  in  this  department  of  his  profes- 
sion as  in  any  other. 

Observe,  gentlemen,  I  speak  not  of  French  but  of  Irish  hospitals ; 
for,  with  the  exception  of  the  objection  already  adverted  to,  the  conduct 
of  the  French  medical  men  is  in  every  respect  praiseworthy.  We  do 
not  find  them  indulging  in  coarse,  harsh,  and  even  vulgar  expressions 
to  their  hospital  patients;  we  do  not  find  them  provided  with  two  voca- 
bularies— one  for  the  rich,  and  another  for  the  poor.t  The  medical, 
more  than  any  other  profession,  requires  that  the  better  feehngs  of  our 
nature  should  be  cultivated  and  fostered.  The  nature  of  anatomical 
pursuits  obliges  us  to  violate  many  of  our  natural  prejudices,  and  dis- 
regard some  of  our  strongest  propensities ;  let  us  therefore  be  doubly 
anxious  to  give,  by  means  of  the  most  diligent  cultivation,  an  addi- 
tional and  more  vigorous  growth  to  our  better  feelings — to  our  social 
affections ; — and  if  we  are  accused  of  disrespect  for  the  dead,  let  us 
answer  the  accusation  by  our  humanity  to  the  living. 

But  to  return  to  our  subject.  The  third  mode  of  conducting  clinical 
instruction,  is  that  adopted  generally  throughout  Germany ;  and  which, 
in  addition  to  the  means  of  improvement,  comprehended  in  the  plan 
of  the  French  and  English  methods,  possesses  the  advantage  of  allowing 
the  more  advanced  students  to  undertake  the  care  of  patients  in  the 
hospital,  under  the  direction  of  the  attending  physician. 

The  importance  of  clinical  instruction  is  so  much  felt  in  Germany, 
that  each  school  has  three  distinct  medical  clinics  attached  to  it,  by 
which  means  the  labour  of  teaching  is  divided  among  the  professors, 
and  the  number  of  students  attending  each  is  diminished.  There  is 
one  clinical  hospital  for  the  treatment  of  acute  diseases,  and  another 
for  chronic  diseases,  while  a  clinical  dispensary  is  devoted  to  the  care 
of  extern  patients.  The  pupils  are  divided  into  two  classes, — the  more 
advanced,  who  get  the  care  of  patients, — and  the  junior  students,  who 

*  This  rule  is  always  observed  in  Germany,  a  country  remarkable  for  the  zeal  and 
humanity  of  the  medical  profession.  In  Italy  both  professors  and  students  are  less 
scrupulous.  Thus  Dr.  Clark  relates  that  he  has  heard  the  case  of  a  phthisical  person 
explained,  in  all  its  bearings,  by  the  professor  of  Bologna,  in  the  patient's  presence :  in 
another  instance,  which  occurred  at  the  same  place,  a  female,  labouring  under  cancer 
uteri,  burst  into  tears  on  hearing  a  detailed  account  of  the  nature  of  her  complaint ! 

•\-  When  the  above  lecture  was  delivered,  the  abuse  I  speak  of  was  but  too  frequent ; 
and  will  it  be  credited  that  many  other  and  greater  abuses  had  existed  during  the  prece- 
ding generation  ?  Death,  the  most  efficient  of  all  reformers,  had  then  removed  several 
of  the  chief  actors  from  the  scene,  for  which,  as  on  most  other  occasions,  he  has,  I  rather 
think,  been  undeservedly  censured.  "* 


10  CLINICAL   MEDICINE. 

merely  look  on  and  listen.  When  a  patient  is  admitted,  his  case  is 
assigned  to  one  of  the  practising  pupils,  who,  when  the  physician  is 
visiting  the  ward,  reads  out  the  notes  he  has  taken  of  the  patient''s 
disease,  including  its  origin,  progress,  and  present  state.  This  is  done 
at  the  bed-side  of  the  patient ;  and  before  he  leaves  the  ward,  the  phy- 
sician satisfies  himself  whether  all  the  necessary  particulars  have  been 
accurately  reported  by  the  pupil.  After  all  the  patients  have  been  thus 
accurately  examined,  the  professor  and  his  class  proceed  to  the  lecture- 
room,  and  a  list  of  the  patients  and  the  practising  pupils  is  handed  to 
the  professor  :  the  cases  admitted  that  day  are  first  inquired  into,  and 
the  pupils  are  examined  concerning  the  nature  of  their  diseases,  their 
probable  termination,  and  the  most  appropriate  method  of  treatment, — 
each  student  answering  only  concerning  the  patients  entrusted  to  his 
special  care.  During  this  examination,  the  pupiFs  diagnosis  and  pro- 
posed remedies  are  submitted  to  the  consideration  of  the  professor,  who 
corrects  whatever  appears  to  be  erroneous  in  either,  and  then  the 
student  retires  to  write  his  prescriptions,  while  the  rest  of  the  cases 
and  pupils  undergo  a  similar  examination.  At  the  conclusion,  the 
prescriptions  written  by  the  students  are  read  out  in  order  by  the  pro- 
fessor, who  strictly  comments  on  and  corrects  any  inaccuracy  or  inele- 
gance they  may  contain.  When  the  prescriptions  have  been  revised 
and  corrected,  they  are  signed  by  the  physician,  and  handed  to  the 
apothecary  to  be  made  up  and  distributed.  In  some  clinics,  the  price 
of  each  medicine  is  affixed  to  the  bottle  or  box  containing  it,  in  order 
that  the  students  may  become  acquainted  with  the  comparative  expense 
of  various  prescriptions,  and  may  thus  be  enabled,  in  private  practice, 
to  accommodate,  as  far  as  is  possible,  the  expense  of  the  remedies  to 
the  circumstances  of  their  patients.  The  clinic  for  extern  patients  is 
conducted  on  the  same  principles :  patients  who  are  able  to  attend,  are 
examined  at  the  dispensary ;  those  who  cannot  leave  their  homes  are 
visited  by  the  senior  practising  students,  who  always  seek  the  advice  of 
the  professor  when  the  case  is  urgent,  or  the  treatment  doubtful. 
Nothing,  gentlemen,  can  be  better  adapted  than  this  plan  of  cHnical 
instruction  for  the  improvement  either  of  the  beginner,  or  of  the  more 
advanced  student;  this  daily  deliberation  and  anxious  discussion  con- 
cerning the  nature  and  treatment  of  each  ease,  is  peculiarly  interesting, 
and  serves  to  accustom  the  beginner  to  habits  of  accurate  examination, 
whereby  he  is  taught  to  interrogate  nature  for  himself,  and  learn  the 
history  and  treatment  of  disease,  not  from  books  and  descriptions,  but 
from  direct  observation.  The  advantages  gained  by  the  practising 
pupils  are  too  obvious  to  require  comment :  being  obhged  to  give  rea- 
sons for  every  plan  of  cure  that  they  propose,  they  are  accustomed  to  a 
rational  and  careful  investigation  of  disease ;  and  enjoying  the  most 


CLINICAL   INSTRUCTION.  H 

important   of  all  advantages — the  early  correction   of  their  errors 

they  commence  private  practice  with  a  sufficient  degree  of  experience  to 
render  them  unlikely  to  commit  any  very  serious  mistakes. 

It  is  evident  that,  according  to  the  German  method,  no  regular 
clinical  lectures  are  necessary,  as  the  pupil  becomes  accurately 
acquainted  vpith  the  physician^s  views  of  each  case,  and  no  step  is  taken 
in  the  treatment  without  the  reasons  for  it  being  given.  This  is  the 
best  sort  of  clinical  lecture ;  the  pupils  have  their  doubts  solved,  and 
their  erroneous  views  corrected,  while  the  professor  is  enabled  to  men- 
tion as  the  disease  proceeds,  every  thing  which  he  thinks  illustrative  of 
its  nature. 

Eleven  years  experience,  since  I  first  delivered  the  foregoing  obser- 
vations, enables  me  strongly  to  recommend  the  method  of  instruction 
pursued  in  Germany.  Since  my  appointment  to  the  Meath  Hospital,  I 
have  had  extensive  opportunities  of  observing  its  good  effects.  Not  a 
session  has  elapsed  without  furnishing  proofs  in  its  favour.  This 
system,  however,  at  first  met  with  much  opposition,  and  its  introduc- 
tion was  ridiculed  in  every  possible  manner;  even  now  it  may  be 
doubted  whether  its  well-wishers  are  as  numerous  as  might  be  expected. 
It  is  still  opposed  by  several  narrow-minded  persons,  whose  opinions 
have  much  weight  with  the  pupils. 

I  remember  perfectly  well  having  only  two  practising  pupils  in  one 
class,  but  I  was  not  discouraged ;  and  although  we  have  had  many 
numerous  classes  in  the  Meath  Hospital,  I  doubt  if  any  of  them  con- 
tained more  talent  and  worth  than  was  shared  between  my  two  pupils. 
Dr.  Townsend  and  Dr.  Stokes. 

Since  the  latter,  from  being  my  pupil,  has  become  my  colleague,  he 
has  evinced  the  most  indefatigable  zeal  in  co-operating  with  me  in 
instructing  the  pupils  of  the  Meath  Hospital ;  and  I  am  sure  he  joins 
me  in  testifying  the  constant  gratification  we  have  received  from  observ- 
ing that  our  efforts  have  been  so  far  successful,  that  no  season  elapses 
without  bringing  under  our  immediate  observation  several  pupils  whose 
diligence,  zeal,  and  moral  worth,  insure  our  warmest  approbation. 
Many  of  these  gentlemen  have  already  distinguished  themselves, — and 
will  always  carry  with  them  the  best  wishes  of  myself  and  my  colleague. 

Six  and  twenty  years  have  now  elapsed  since  the  foregoing  part  of 
this  lecture  was  delivered  in  the  old  Meath  Hospital,  and  my  subsequent 
experience  has  amply  verified  the  opinions  therein  expressed.  I  regret 
to  say,  that  however  influential  these  opinions  may  have  proved  in  this 
city,  their  promulgation  has  produced  but  little  benefit  in  causing  any 
alteration  in  the  mode  of  instruction  pursued  in  the  medical  schools  of 
the  United  Kingdom  at  large.     So  far  indeed  from  the  mode  of  con- 


12 


CLINICAL   MEDICINE. 


ducting  medical  education  being  improved  it  has  decidedly  been  altered 
for  the  worse.  This  assertion  may  appear  paradoxical^  nay  almost 
incredible^  when  it  is  recollected  how  many  new  Universities  and 
Schools  have  arisen  since  the  year  1821 ;  and  how  many  novel  medical 
professorships  have  been  founded. 

But  if  we  carefully  examine  into  the  instructions  given,  and  the 
qualifications  required  in  the  first  and  most  recently  organized 
medical  school  of  the  day,  viz.  that  of  the  London  University, 
it  would  readily  appear  that  a  very  small  part  of  the  student's 
time  and  attention  is  directed  to  acquire  a  knowledge  of  how  disease 
is  to  be  actually  treated  and  cured — unless,  indeed,  we  admit  that 
a  knowledge  of  Greek  and  Latin,  of  mathematics,  algebra,  and 
optics,  of  physics,  botany,  and  chemistry,  is  necessary  for  this 
purpose.  That  this  multiplicity  of  subjects  distracts  every  student  is 
sufficiently  evident  a  priorL  And  my  own  experience,  from  opportu- 
nities as  a  public  teacher  for  many  years,  has  satisfactorily  convinced 
me  that  the  practical  parts  of  medicine  are  not  taught  so  well  now  as 
formerly. 

It  is  not  intended  to  assert  that  pupils  now  hear  fewer  clinical 
lectures  or  attend  a  shorter  time  in  the  Hospital,  but  it  may  be 
confidently  affirmed  that  what  they  hear  in  these  lectures,  or  see  in  the 
hospital,  does  not  rivet  attention  or  excite  reflection  now  as  formerly. 
Tor  the  pupiFs  avocations  are  so  numerous  that  he  is  hurried  from  one 
to  the  other,  and  has  no  time  to  devote  to  serious  reflections  upon  what 
he  has  seen. 

In  Edinburgh,  the  engrossing  subject  of  conversation  amongst 
students  used  to  be  the  nature  of  the  diseases  of  the  clinical 
patients,  and  the  effects  of  remedies  employed ;  the  clinical  ward 
afforded  constant  themes  for  discussion,  and  its  contents  were  con- 
stantly before  the  thoughts  of  the  student.  Such  was  Edinburgh 
in  1819,  how  it  may  be  now,  I  cannot  tell ;  but  be  it  changed 
for  the  worse,  which  I  hope  is  not  the  case,  it  must  result  from  a 
change  in  the  system,  and  not  a  deterioration  in  the  professors,  whose 
unwearied  diligence  in  the  promotion  of  medical  science  daily  brings 
forth  fruit  not  unworthy  of  the  best  era  of  their  predecessors. 

When  so  many  seductive  subjects  are  successively  placed  before  the 
student,  it  cannot  be  expected  that  he  will  think  almost  exclusively  on 
what  is  practical.  On  the  contrary  the  chances  are  ihat  the  chief  energies 
of  his  mind  will  be  mispent  on  the  fascinating  experiments  and  doctrines 
of  chemistry,  electricity,  magnetism,  and  the  polarization  of  light,  to 
the  exclusion  of  the  less  fascinating  but  all-necessary  subject  of  disease 
and  its  treatment.  In  truth,  the  very  rapid  advances  in  the  so  named 
collateral  sciences  have,  of  late  years,  seemed  to  render  the  practical 


CLINICAL   INSTRUCTION.  13 

improvement  of  the  student  less  probable,  and  every  day  it  becomes 
more  unlikely  that  he  will  attain  to  the  simple  goal  that  he  ought  to 
hold  in  view,  but  will  be  diverted  from  the  pursuit  of  the  one  indis- 
pensable object  by  the  very  means  which  he  is  taught  to  beheve  are 
necessary  for  its  attainment.  To  this  subject  I  shall  recur  in  the 
following  lecture,  concluding  this  with  an  expression  of  satisfaction 
that  since  the  first  publication  of  my  views  upon  medical  education, 
they  have  been  brought  forward  and  enforced  in  several  leading  articles 
by  the  able  Editor  of  the  Medical  Gazette;  and  they  have  had,  I  have 
reason  to  hope,  a  favourable  effect  upon  the  manner  in  which  medical 
education  is  conducted  in  my  native  city. 


14 


LECTURE  11. 


PRELIMINARY   EDUCATION. MODiaiN    NOMENCLATURE. — 


Having  now  explained  the  advantages  of  this,  the  German  mode  of 
clinical  instruction,  I  shall  content  myself  with  remarking  that  we  have 
had  many  years'  experience  of  its  beneficial  effects  in  the  Meath  Hos- 
pital, where  it  was  introduced  by  myself  in  1821 ;  I  must  remind  you, 
however,  that  even  its  utility  is  necessarily  proportioned  to  the  diligence 
of  the  student.  There  is  no  system  capable  of  communicating  infor- 
mation to  the  indolent ;  every  man  must  depend  chiefly  on  his  own 
assiduity,  and  all  the  teacher  can  do  is  to  facilitate  the  means  of  ac- 
quiring knowledge,  and  afford  an  example  of  punctuality  and  attention. 
I  would  seriously  recommend  every  one  who  undertakes  the  manage- 
ment of  cases,  to  set  out  with  a  fixed  determination  to  persevere 
throughout  the  whole  session.  Eew  things  give  me  more  concern  than 
to  find  young  men,  who  have  commenced  with  ardour,  becoming  by 
degrees  less  and  less  industrious,  until  their  hospital  attendance  degen- 
erates into  an  irksome  task,  imperfectly  performed,  and  at  last  wholly 
neglected.  One  of  the  most  valuable  things  which  the  student  can 
acquire,  is  a  habit  of  daily  diligence.  The  knowledge  requisite  for  the 
efficient  discharge  of  our  professional  duties  is  not  to  be  acquired  by 
sudden  starts  of  intense  application,  or  by  the  overwrought  strivings  of 
desultory  exertion ;  it  demands  a  daily  and  hourly  attention,  a  steady, 
constant,  and  accurate  course  of  observation,  continued  uninterruptedly 
for  years. 

I  think  students  are  very  much  misled  as  to  the  best  mode  of  be- 
coming good  practitioners.  This  is  an  age  of  ambitious  acquirement, 
and  professional  men  seem  to  be  ashamed  unless  they  have  the  char- 
acter of  universal  knowledge.  Every  body  studies  every  thing,  and  the 
consequence  is  that  few  know  any  thing  well.  We  live  amidst  the  din 
of  declamations  in  favour  of  general  education ;  and  are  every  where 
assailed  by  the  ceaseless  competition  of  those  who  vend  cheap  know- 
ledge in  the  form  of  penny  periodicals,  lectures  innumerable,  and  hosts 
of  rival  encyclopaedias ;  but  ours  is  not  an  age  of  calm  unpretending 


PRELIMINARY  EDUCATION.  15 

acquirement  and  severe  precise  study,  without  which,  the  effort  to 
become  good  physicians  and  surgeons  must  prove  vain  and  fruitless. 

Can  any  thing  be  more  embarrassing  than  the  multitudinous  array  of 
studies  presented  to  the  young  student,  who  comes  to  London  or 
Dubhn  with  the  view  of  educating  himself  as  a  general  practitioner? 
So  many  departments  of  knowledge  are  spread  before  him,  and  so 
numerous  are  the  exhortations  to  study  each  with  particular  care,  that 
he  feels  at  a  loss  where  to  begin.  The  merits,  advantages,  and  ne- 
cessity of  his  own  branch,  are  insisted  on  by  the  respective  teachers, 
with  all  the  force  of  impressive  eloquence ;  and  after  running  tlie  round 
of  introductory  lectures — an  initiatory  penance  duly  performed  by  all 
beginners,  he  returns  in  the  evening  to  his  home,  puzzled  and  dispirited. 
He  finds  that  it  will  be  necessary  for  him  to  become  an  excellent 
botanist,  an  able  and  scientific  chemist,  and  a  profound  anatomist ;  that 
he  must  have  some  knowledge  of  zoology,  be  well  versed  in  compara- 
tive anatomy,  know  how  to  detect  poisons  with  accuracy,  and  study  the 
legislative  enactments  which  bear  on  questions  of  medical  jurisprudence. 
Physiology,  materia  medica,  therapeutics,  nosology,  morbid  anatomy, 
the  principles  and  practice  of  surgery,  medicine,  and  midwifery,  claim, 
all  and  each,  his  especial  attention ;  nay,  many  teachers  insist  upon  the 
necessity  of  his  becoming  master  of  several  languages — Greek,  Latin, 
French,  and  German  :  while  others  assure  him  that  he  never  can 
prosecute  scientific  medicine  with  success,  unless  he  studies  physics  as 
weU  as  physic  :  some  are  there  even  who  encourage  him  to  cultivate 
mineralogy  and  geology,  as  if  forsooth  a  knowledge  of  these  sciences 
could  teach  the  laws  that  regulate  diseased  action,  or  the  indications 
which  should  govern  the  exhibition  of  remedies.  In  a  lecture  pubHshed 
by  Mr.  Hayden,  I  find  it  remarked  "  that  to  keep  pace  with  the  modem 
race  of  intellect,  we  should  get  on  a  railroad  of  literature ;  mathematics, 
natural  philosophy,  the  art  of  drawing,  and  above  all,  logic,  will  be 
indispensable.''^  Dr.  EUiotson  would  no  doubt  add  metaphysics,  animal 
magnetism,  and  phrenology,  sciences  he  has  cultivated  with  success,  and 
taught  with  perspicuity  !  Dr.  Latham,  who  has  had  sufiicient  courage 
to  put  forth  his  opinions  on  this  subject,  has  demonstrated,  wdth  much 
truth  and  force,  the  injustice  and  folly  of  attempting  to  impose  so  many 
burthens  on  the  minds  of  students,  and  has  shown  clearly  the  bad  con- 
sequences resulting  from  such  a  mode  of  proceeding. 

No  profession  requires  a  sounder  preliminary  education  than  ours, 
and  in  none  ought  education  be  more  studiously  directed  to  promote 
the  activity  and  development  of  the  mental  powers,  especially  those 
connected  with  the  habit  of  observation  as  well  as  with  the  judgment 
and  memory.  The  latter  faculty  should  be  cultivated  from  the  earhest 
period,  and  the  boy  should  be  taught  the  chief  anatomical  names,  as 


16  CLINICAL   MEDICINE. 

those  of  the  different  parts  of  the  muscular^  nervous,  and  vascular 
systems,  which  names  he  will  of  course  find  no  difficulty  in  retaining 
when  a  man,  and  it  will  then  be  only  necessary  to  learn  the  qualities  of 
the  things  to  which  they  belong.  If,  in  addition  to  this,  boys  were 
taught  the  scientific  names  of  the  chief  articles  of  the  materia  medica^ 
and  the  technical  terms  and  classifications  of  botany  and  chemistry, 
much  trouble  would  be  saved  them  in  after  life ;  and  their  memories, 
while  in  the  state  of  greatest  activity,  would  be  much  better  employed 
than  in  attaining  the  rules  and  terms  of  syntax,  prosody,  mythology, 
and  ancient  geography. 

I  would  not  recommend  any  one  to  commence  the  actual  study  of 
medicine  and  surgery  until  the  age  of  nineteen.  Before  that  period 
the  mind  is  not  sufficiently  ripe  for  practical  observation,  nor  sufficiently 
stored  with  that  knowledge — only  to  be  gained  by  the  daily  intercourse 
of  life — which  teaches  us  to  estimate  the  effects  of  moral  or  physical 
causes  on  the  human  system,  imparts  to  us  the  power  of  weighing 
conflicting  evidence,  and  detecting  the  too  frequently  incorrect  and 
erroneous  statements  of  our  patients.  A  certain  knowledge  of  the 
world  is  indispensable  to  the  physician ;  and  it  is  only  loss  of  time — 
yes,  of  precious  time — to  employ  boys  in  trying  to  learn  what  can  only 
be  acquired  by  men.  Those  who  attend  hospitals  at  too  early  an  age 
are  very  apt  to  acquire  careless  habits  of  observation ;  all  the  interest 
which  disease  presents,  when  observed  for  the  first  time  by  matured 
minds,  is  lost  to  them,  and  all  the  attractions  of  novelty  have  ceased 
long  before  they  possess  that  tact  and  experience  which  enable  the 
adult  to  understand  the  meaning  of  symptoms,  the  progress  and  phases 
of  morbid  phenomena,  and  the  effects  of  therapeutic  agents. 

It  is  then  the  duty  of  parents,  guardians,  teachers,  and  aU  who 
superintend  the  education  of  youth,  to  see  that  those  who  are  destined 
for  the  medical  profession  should  have  their  minds  prepared  and 
strengthened  by  diligent  cultivation  during  early  youth,  not  only  by 
the  attainment  of  extra-professional  knowledge  suited  to  their  means 
and  opportunities,  but  also  by  instruction  in  those  portions  of  ana- 
tomy, materia  medica,  botany,  and  chemistry,  which  may  be  readily 
comprehended  at  that  age.  Especial  care  should  be  taken  to  impart 
to  them  some  knowledge  of  the  physical  qualities  of  medicinal  sub- 
stances. All  this  being  done,  when  the  student,  arrived  at  maturer 
years,  comes  to  grapple  with  the  practical  departments  of  his  profession, 
he  will  find  many  difficulties  easily  surmounted,  and  at  this  period  he 
should  disengage  himself  from  too  devoted  an  attention  to  the  accessory 
sciences.  But  he  need  not  wholly  detach  himself  from  them ;  some 
one  of  them  may  be  cultivated  along  with  his  more  serious  pursuits. 
He  may  devote  one  session  to  lectures  on  chemistry,  another  to  those 


PRELIMINARY  EDUCATION.  17 

on  botany,  a  third  to  physiology,  and  so  on  of  the  rest.  But  his  main 
object  must  now  be  the  acquisition  of  practical  knowledge,  and  conse- 
quently the  greater  portion  of  his  time  and  energies  must  be  devoted 
to  the  chnical  wards  and  dissecting-room  of  an  hospital,  to  the  study  of 
materia  medica  and  pharmacy  in  an  apothecary's  shop,  and  to  practical 
anatomy. 

Five  or  six  years'  attendance  on  an  hospital  will  be  little  enough  to 
qualify  you  to  enter  with  propriety  and  confidence  on  the  discharge  of 
your  professional  duties.  Bear  in  mind,  gentlemen,  that  when  you 
come  to  treat  disease,  you  approach  the  bedside  as  physicians  or 
surgeons,  and  not  as  chemists,  botanists,  or  anatomists.  This  is  the 
character  in  which  you  are  to  appear ;  and,  to  the  acquisition  of  know- 
ledge which  will  prepare  you  for  the  discharge  of  its  duties,  you  ought 
to  apply  your  chief  attention. 

Some  of  you,  gentlemen,  may  think  that  it  ill  becomes  a  teacher  to 
narrow  the  limits  of  your  exertions,  or   circumscribe   your  pursuits. 
But  let  me  be  understood.     A¥hat  I  wish  to  impress  upon  your  atten- 
tion is,  that  you  ought  to  address  yourselves  mainly  to  the  acquirement 
of  what   is   really   useful,   and  should  store  up  chiefly  what  is  most 
important  and  available.     And  in  furtherance  of  this  object  I  think  it 
my  duty  to  warn  you  against  the  well-meaning  but  injudicious  repre- 
sentations of  those  who  would  turn  you  from  the  study  of  practical 
matters  to   the  cultivation  of  their  favourite  sciences — sciences  con- 
nected with  and  ancillary  to  medicine,  but  in  which  medical  students 
are  too  often  encouraged  to  engage  with  an  ardour  that  indirectly,  but 
certainly,  leads  to  a  less  zealous  and  efficient  attention  to  more  impor- 
tant matters.     Take,  for  instance,  two  of  the   most   popular   of  the 
adjunct  sciences — two  usually  regarded  as  most  intimately  connected 
with  the  study   of  medicine — botany   and  chemistry.     Both  are   ex- 
tremely valuable  in  themselves,  and  a  certain  acquaintance  with  them  is 
undoubtedly  desirable ;  but  to  the  student  in  medicine  their  utility  has 
been  greatly  overrated.     Botany  is  an  extremely  interesting  and  useful 
science ;  but  I  beheve  you  might  be  very  good  practitioners  without 
knowing  the  classes  of  Linnaeus,   or  the  families  of  Jussieu.     To  be 
sure,  if  you  had  the  misfortune  to  practice  in  localities  separated  from 
the  ordinary  channels  of  commerce;  if  you  were  suddenly  bereft   of 
the  numerous  stores  which  maritime  enterprise  pours  into  the  lap  of 
medicine,  and  obhged,  like  the  herbalists  of  old,  to  search  the  woods 
and  fields  for  your  materia  medica,  you  would  certainly  be  often  at  a 
loss,  and  might  make  some  serious  mistakes,  unless  you  were  adepts  in 
practical  botany.     But  tliis  labour,  fortunately  for  us  and  for  every 
European  practitioner,   is   quite   unnecessary.      A   small   capital   will 
bring  the  vegetable  productions  of  the  most  distant  countries  to  your 

VOL.   I.  2 


IB  CLINICAL    MEDICINE. 

door ;  and  any  respectable  druggist  will  for  a  trifling  sura  provide  you 
with  all  the  medicinal  substances  derived  from  plants,  carefully  selected 
and  accurately  prepared. 

Those  who  boast  the  most  loudly  of  their  acquisitions  in  botany, 
and  who  lay  most  stress  on  its  importance,  know  very  well  that  to  the 
physician  it  is  of  little  or  no  practical  value.  Take  one  of  the  best  of 
our  English  or  Irish  botanists,  and  see  how  meagre  a  knowledge  he 
possesses  after  all,  of  many  of  the  plants  whose  products  are  employed 
so  largely  every  day  in  the  treatment  of  disease.  Transport  him  sud- 
denly to  the  East  or  West  Indies,  to  Africa,  or  South  America,  ask 
him  to  show  you  the  camphor  or  the  cinnamon-tree,  the  cajeput,  the 
croton,  or  the  guaiacum :  I  doubt  very  much  whether  he  would  be  able 
to  recognise  logwood,  or  even  ipecacuanha,  growing  in  their  natural 
situations.  Again,  there  are  a  great  many  vegetable  productions  used 
every  hour  in  medicine,  of  which  it  may  be  said,  that  no  two  botanists 
are  agreed  as  to  the  precise  description  of  plant  from  which  they  are 
derived.  There  is  no  substance  in  such  common  use  as  gum  Arabic, 
and  yet,  notwithstanding  all  that  has  been  written  on  the  subject,  it  is 
not  clear  from  what  particular  plants  it  is  derived.  Nor  do  I  think  it 
necessary  to  know  whether  the  gum  we  use  in  compounding  a  cough 
medicine  comes  from  the  Acacia  vera  or  Acacia  Arabica.  In  like 
manner,  the  plants  which  furnish  cardamoms  and  many  other  substances 
in  common  use  are  by  no  means  determined.  How  many  disputes 
have  there  been  with  respect  to  the  geims  Cinchona  ?  And  what  has 
been  the  result  of  all  our  investigations  concerning  the  plant  which 
produces  this  great  remedy.  Listen  to  what  my  late  learned  friend 
Andrew  Duncan  says,  in  the  Supplement  to  the  Dispensatory  :  "  Not- 
withstanding that  all  the  British  colleges  agree  as  to  the  botanical 
species  of  cinchona  from  which  the  commercial  varieties  of  bark  are 
derived,  there  is  no  satisfactory  evidence  that  they  are  right ;  on  the 
contrary  it  is  almost  certain  that  in  regard  to  some  of  them  they  are 
wrong."*^  How  many  years  were  calumba  and  many  other  similar  pro- 
ductions employed,  before  scientific  botanists  knew  any  thing  of  their 
true  history?  In  1829  a  paper  was  read  by  Dr.  Hancock,  on  the  tree 
which  yields  the  Angostura  bark ;  it  appears  that  even  Bonpland  and 
Humboldt  had  described  the  wrong  tree,  and  consequently  it  has  been 
called  for  many  years  a  Bonplandia  j  whereas  it  belongs,  it  now  ap- 
pears, to  another  genus,  named  Galipea.  Dr.  Hancock  has  also  proved 
that  the  Smilax  syphilitica  of  Wildenow  is  not  the  true  sarparilla,  but 
that  it  is  obtained  from  other  plants :  and  at  what  conclusion  does 
Dr.  Hancock,  who  spent  many  years  in  South  America  arrive  ?  Why 
that  the  only  criterion  for  knowing  good  sarsaparilla  is  its  taste  when 
chewed !     In  proof  of  the  uncertainty  which  still  prevails  concerning 


THE    STUDY    OF    BOTANY.  19 

the  determination  of  species  used  in  medicine,  I  have  only  to  refer  you 
to  the  admirable  lectures  of  Mr.  Pereira  in  the  Medical  Gazette^  and 
those  of  Dr.  Sigmond  published  in  the  Lancet."^ 

I  do  not  wish  to  undervalue  botany  as  a  part  of  general  education. 
Eew  sciences  are  more  attractive,  and  few  are  more  likely  to  become  an 
object  of  enthusiastic  pursuit ;  but  it  is  the  very  enthusiasm  it  is  so 
likely  to  generate  that  I  wish  to  warn  you  against.  Botany  is  an  ex- 
cellent exercise  for  the  minds  of  youth :  it  gives  habits  of  accuracy  of 
observation,  and  tends  to  strengthen  the  memory.  It  leads  to  healthy 
occupation,  and  affords  a  source  of  innocent  enjoyment.  As  productive 
of  so  much  good,  let  it  form  a  part  of  the  education  of  young  persons 
in  general ;  sure  I  am  that  its  cultivation  would  give  a  healthier  tone 
to  both  mind  and  body,  than  is  to  be  obtained  from  many  of  the 
studies  with  which  boys  are  now  tortured  in  the  schools.  But  let 
botany  be  restricted  within  its  proper  limits ;  and  when  once  young 
men  have  seriously  engaged  in  the  acquirement  of  medical  and  surgical 
knowledge,  let  them  not  entertain  the  ambition  of  becoming  accom- 
pHshed  botanists. 

*  In  the  number  of  the  Quarterly  Review  for  June,  1842,  we  find  some  very  pertinent 
observations  upon  the  ridiculous  names  given  to  many  flowers,  and  the  inconveniences 
likely  to  arise  from  the  frequent  changing  of  them. 

The  reviewer  says,  *'  Before  we  have  done  with  the  florists  and  botanists,  we  must  say 
one  word  about  their  nomenclatures.  As  long  as  the  extreme  vulgarity  of  the  one  and 
the  extreme  pedantry  of  tlie  other  continue,  they  must  rest  assured  that  they  will  scare  the 
majority  of  this  fastidious  and  busy  world  from  taking  any  great  interest  in  their  pursuits." 

After  objecting  to  many  modern  names,  he  adds,  "  Surely  there  is  marked  character 
enough  about  every  plant  to  give  it  some  simple  English  name,  without  drawing  either 
upon  living  characters  or  dead  languages.  It  is  hard  work,  as  even  Miss  Mitford  has 
found  it,  to  make  the  maurandias,  and  alstraemerias,  and  escholtzias — the  commonest 
flowers  of  our  modern  gardens— look  passable  even  in  prose  :  they  are  sad  dead  letters  in 
the  glowing  description  of  a  bright  scene  in  June.  But  what  are  these  to  the  polloposte- 
monopetelas  and  eleutheromacrostemones  of  Wachendorf,  with  such  daily  additions  as  the 
native  name  of  iztactepotzacuxochitl  icohueyo,  or  the  more  classical  ponderosity  of  Erj- 
symum  Perofskyanum  ? 

"  Like  the  Verbum  Graecum, 
Spermagoraiolekitholakanopolides, 
Words  that  should  only  be  said  upon  holidays, 
When  one  has  nothing  else  to  do. 

"  To  make  confusion  worse  confounded,  our  botanists  are  not  satisfied 

with  their  far-fetched  names;  they  must  ever  be  changing  them  too.  Thus  it  is  a  mark 
of  ignorance  in  the  world  of  flowers,  to  call  our  old  friend  Geranium  otherwise  than 
Pelargonium;  the  Glycine,  (G.  Sinensis,)  the  well  known  specimen  of  which,  at  the 
Chiswick  gardens,  produced  more  than  9000  of  its  beautiful  lilac,  laburnum-like  racemes 
from  a  single  stem,  is  now  to  be  called  Wistaria  ;  the  new  Californian  annual  iEnothera 
is  already  Godetia  ;  while  the  pretty  little  red  Hemimeris,  once  a  Celsia,  is  now  (its 
third  designation)  an  Alonsoa  ;  and  our  list  is  by  no  means  exhausted.  Going  on  at  this 
rate,  a  man  might  spend  the  morn  of  his  life  in  arriving  at  the  present  slate  of  botanical 
science,  and  the  rest  of  his  days  in  running  after  its  novelties  and  changes.  We  are  only 
too  glad  when  public  sanction  triumphs  over  individual  whim,  and,  as  in  the  cases  of 
Georgina  proposed  for  Dahlia,  and  Chryseis  for  Escholtzia,  resists  the  attempted  change." 


20  CLINICAL   MEDICINE. 

Speaking  of  botany,  I  may  observe  that  it  is  much  to  be  regretted 
that  the  names  of  plants  should  undergo  so  many  mutations.  What, 
was  formerly  called  Stilozobium  has  successively  become  Dolichos  and 
Mucuna ;  while  Iceland  moss  has  been  changed  from  Lichen  into  Ce- 
traria,  and  Secale  comutum  into  Acinula  clavus.  Uva  ursi  is  now 
preceded  by  the  prsenomen  Arctostaphylos ;  and  our  old  acquaintance 
jalap,  deprived  of  its  euphonius  prefix  Convolvulus,  has  degenerated 
into  Ipomsea,  still  further  converted,  more  recently,  into  Exogonium. 
All  these  changes  are  useless  or  injuiious,  and  entail  as  a  necessary 
consequence,  that  the  young,  the  middle  aged,  and  the  advanced 
in  life,  use  a  different  medical  vocabulary.  The  materia  medica, 
too,  as  now  taught  by  scientific  professors,  presents  a  serious  stum- 
bling block  to  students.  Teachers  do  not  confine  themselves  to 
showing  the  difi'erent  drugs  and  preparations,  but  they  enter  into  very 
minute  details  of  their  natural  liistory  and  characters ;  so  that  the 
student  cannot  learn  the  properties  of  bees'  wax  without  being  en- 
tangled in  the  difficulties  of  entomology,  or  the  nature  of  isinglass 
without  learning  the  hard  names  used  in  ichthyological  classification. 

The  same  observations  apply  to  chemistry.  It  is  a  science  fully  as 
attractive  as  botany,  and  medical  men  are  apt  to  spend  too  much  time  in 
its  pursuit.  Some  very  pertinent  observations  on  this  subject  have  at  dif- 
ferent periods  appeared  in  the  Medical  Gazette,  to  wliich  I  refer  you  : 
they  are  conceived  in  a  spirit  of  good  sense  and  sound  judgment,  and 
you  will  find  them  well  worthy  of  an  attentive  perusal.  I  grant  that 
it  may  appear  very  like  a  paradox  to  say,  you  need  not  know  much 
practical  chemistry.  But  if  you  go  to  a  reputable  druggist  with  money 
in  your  pocket,  he  will  furnish  you  with  all  the  chemicals  you  have 
need  of,  excellent  in  their  kind,  and  prepared  with  scrupulous  exactness. 
So  far  as  chemicals  are  required  for  medicinal  uses,  you  can  have  them 
all  of  the  best  description.  But  it  will  be  said,  that  Mdthout  an  accu- 
rate and  extensive  knowledge  of  chemistry  you  cannot  prescribe.  This 
is  an  assertion  to  which  I  cannot  assent.  A  very  hmited  knowledge 
indeed  of  chemistry  will  enable  you  to  ascertain  what  substances  are 
compatible  with  each  other,  and  a  smaU  share  of  attention  will  prevent 
you  from  making  any  important  mistakes.  Besides,  you  are  all 
aware  that  many  of  our  best  prescriptions  contain  incompatible  ingre- 
dients ;  and  that  many  compounds  which  would  be  sneered  at  by  the 
mere  chemist,  as  heterogeneous  and  absurd,  prove  decidedly  efficacious 
in  medicine.  Granting  that  a  certain  degree  of  chemical  knowledge  is 
requisite,  it  does  not  follow  that  you  should  be  scientific  and  accom- 
plished chemists.  It  is  not  necessary  that  you  should  dive  into  all  the 
arcana  of  the  science,  or  have  your  memories  loaded  with  atomic 
numbers,  symbols,  and  equivalents. 


THE    STUDY    OF    CHEMISTRY.  21 

Let  me  repeat  with  respect  to  cliemistry  what  has  been  already  ob- 
served concerning  botany.  Students  should  attend  one  or  two  courses 
of  this  science  as  preparatory  to  the  study  of  medicine,  and  during  the 
period  of  that  study  they  may  attend  another,  in  order  to  keep  up  and 
improve  their  knowledge ;  but  they  should  never  allow  chemistry  to 
cause  them  to  absent  themselves  from  the  hospital  for  a  single  day. 
Theoretical  and  philosophical,  call  for  your  attention,  less  than  animal 
and  pharmaceutical  chemistry. 

But  you  are  told  that  you  may  be  called  on  to  decide  questions  of 
medical  jurisprudence,  which  demand  an  accurate  knowledge  of  chem- 
istry ;  that  you  will  be  required  to  test  poisons,  and  detect  them  when 
accidentally  or  purposely  mixed  with  food  or  drink.  What  should 
you  do  in  such  cases  ?  Why,  do  not  undertake  any  investigations  of 
the  kind,  refuse  to  make  them,  refer  them  to  those  who  are  competent 
to  the  task.  Where  will  you  find  a  man  engaged  in  the  practice  of 
physic  fully  capable  of  deciding  such  questions?  Wliat  practising 
physician  or  surgeon  is  competent  to  enter  at  once  upon  an  investigation 
of  tliis  nature  ?  I  have  lectured  some  three  or  four  years  on  medical 
jurisprudence,  and  have  bestowed  a  good  deal  of  attention  on  the  sub- 
ject, and  yet  if  called  on  to  decide  a  case  of  poisoning,  I  would  refuse, 
and  say  I  was  incompetent  to  the  task.  What  then  is  to  be  done 
under  such  circumstances  ?  Tliis  is  a  matter  of  deep  importance  to 
society.  It  is  of  the  utmost  consequence  that  the  wretch  who  poisons 
should  not  escape,  and  that  the  innocent  should  not  suffer.  It  there- 
fore behoves  the  Government  to  employ  and  pay  persons  capable  of 
deciding  such  questions.  Then,  and  not  till  then,  will  the  task  be  duly 
performed,  and  the  decisions  be  such  as  the  public  can  look  up  to  with 
respect  and  confidence. 

So  far  with  respect  to  a  knowledge  of  chemistry  as  connected  with 
the  choice  and  prescription  of  medicines,  or  the  analysis  of  poisons. 
As  to  any  benefits  derived  from  analytical  chemistry  in  solving  the 
problems  of  vital  action,  or  elucidating  the  functions  of  the  various 
organs  in  health  and  disease,  they  may  be  said  to  be  few  and  unimpor- 
tant, and  inconclusive.  Tew  and  scanty,  indeed,  are  the  rays  of  light 
which  chemistry  has  flung  on  the  vital  mysteries.  I  am  not  aware 
that  it  has  revealed  any  of  the  master  secrets  of  the  organism,  or 
detected  the  sources  of  those  important  aberrations  from  normal  action 
which  we  are  called  on  to  study  every  day  and  every  hour.  Chemistry 
has  failed  most  remarkably  in  revealing  the  arcana  of  life;  and  not- 
withstanding aU  her  boasted  discoveries,  we  are  still  very  little  in  ad- 
vance of  those  who  practised  the  healing  art  some  centuries  ago. 
Chemists,  the  ablest  of  their  class,  have  bestowed  the  most  minute 
and  unwearied  attention  on  the  analysis  of  fibrin,  and  gelatin,  and 


22  CLINICAL    MEDICINE. 

albumen ;  and  what  have  they  discovered  ?  Simply  this  :  that  sub- 
stances so  apparently  distinct  in  their  vital  relations,  and  so  different, 
or  even  opposed,  in  their  physical  properties,  are  analogous  compounds; 
that  there  is  scarcely  any  difference  in  their  elementary  composition ; 
and  that  their  atomic  constitution  is  nearly  identical.  How  long  have 
chemists  laboured  in  attempting  to  detect  the  cause  of  animal  heat ! 
How  many  experiments  have  been  made  for  the  purpose  of  ascertaining 
the  effect  produced  on  the  air  by  respiration  !  How  many  able  and 
ingenious  men  have  sought  a  chemical  explanation  of  the  difference  in 
point  of  colour  between  arterial  and  venous  blood  !  All  these  inves- 
tigations have  proved  indirectly  useful,  but  none  of  them  have  revealed 
the  secrets  sought;  and  we  are  still  in  profound  ignorance  of  the 
powers  which  direct  and  modify  the  unceasing  operations  of  the  labor- 
atory over  which  life  presides — ^that  mysterious  influence,  which,  like  the 
Deity  from  whom  it  emanates,  is  invisible,  inscrutable,  incomprehensible* 

So  much  for  the  light  which  chemistry  has  shed  on  the  vital  actions, 
and  on  the  nature  of  organized  compounds.  There  are,  to  be  sure, 
one  or  two  instances  in  which  a  rough  examination  of  some  organic 
products  is  necessary :  as,  for  example,  of  the  urine,  in  certain  cases 
of  gout,  gravel,  and  dropsy.  But  even  in  these  instances  a  few  simple 
rules  wiU  suffice,  and  sufficient  information  may  be  obtained  by  one 
moderately  acquainted  with  chemistry.  Generally  speaking,  the  che- 
mical knowledge  requisite  for  the  study  of  disease  is  very  limited ;  and 
those  who  are  engaged  in  the  practice  of  medicine  are  well  aware,  that 
cases  demanding  an  accurate  or  extensive  knowledge  of  chemistry  are 
of  extremely  rare  occurrence. 

Let  me  now  advert  to  a  serious  inconvenience  which  the  chemists 
have  imposed  upon  the  medical  world.  They  have,  it  appears,  not  only 
assumed  to  themselves  the  privilege  of  naming  our  medicines,  but  also 
of  changing  those  names  every  five  or  six  years.  One  of  my  ablest  and 
most  diligent  pupils  (Mr.  Moore)  has  taken  the  trouble  of  drawing  up 
a  table,  shewing  the  various  names  which  have  been  successively  be- 
_  stowed  on  each  substance  since  the  days  of  Lavoisier.  I  have  the  table 
here  before  me,  and  I  find  that  most  chemical  substances  have,  in  the 
space  of  fifty  years,  undergone  at  least  five  changes.  Of  course,  as  the 
march  of  chemistry  progresses  with  accelerated  speed,  we  may  give  our 
nomenclators  credit  for  an  increased  tendency  to  revolutionize  the  che- 
mical vocabulary,  and  conclude  that  they  will  change  them  five  times 
within  the  next  fifty  years.  In  1890,  how  will  a  man  be  able  to  recog- 
nise a  substance  whose  name  has  undergone  ten  mutations  ?  I  am 
anxious  to  dwell  on  this  defect  as  being  pregnant  with  perplexity  and 
confusion.  It  would  almost  seem  as  if  some  enemy  to  our  profession 
had  invented  the  chemical  nomenclature  for  the  purpose  of  retarding 


CHEMICAL   NOMENCLATURE.  23 

the  advance  of  practical  medicine.  Of  what  use  will  a  practice  of 
Physic,  published  in  1800,  be  to  the  reader  who  peruses  it  in  1900? 
We  all  know  how  easily  the  mind  of  man  is  deterred  by  difficulties ; 
how  few  there  are  who  will  submit  to  the  labour  of  becoming  genealo- 
gists in  chemical  names. 

Many  and  able  men  foresaw  this  difficulty  from  the  beginning,  and 
raised  their  voices  against  the  adoption  of  names  meant  to  convey  a 
knowledge  of  the  chemical  composition  of  mineral  and  saline  medicines. 
Bostock  and  Murray  have  both  written  ably  on  this  subject,  and  I 
regret  much  that  their  advice  has  not  been  duly  weighed  and  considered. 
In  practice,  many  serious  inconveniences  arise  from  this  vacillating 
state  of  chemical  nomenclature.  Every  apothecary  knows  that  mistakes 
occur  from  day  to  day,  owing  to  the  shifting  character  of  chemical 
nomenclature,  and  I  think  it  is  time  for  us  to  bestir  ourselves,  and 
make  a  stand  against  the  useless  and  dangerous  innovations  of  the 
chemists.  We  should  come  forward  boldly,  and  declare  that  we  will 
not  be  made  the  slaves  of  names.  Compare  our  last  Pharmacopceia 
with  its  immediate  or  penultimate  predecessor,  and  the  difficulties  a 
physician  has  to  encounter  will  be  obvious.  Are  we  to  be  perpetually 
called  on  to  learn  new  names  ?  Must  an  artificial  method  of  forgetting 
become  even  more  necessary  than  a  memoria  technica  ?  Must  my  pre- 
scriptions of  1818  be  translated  into  a  new  language,  if  I  wish  to  em- 
ploy them  now  ?  It  is  time,  then,  to  protest  seriously  against  having 
our  memories  loaded  with  a  polyglot  vocabulary,  and  our  ideas  confused 
by  a  perpetual  alteration  of  names.  I  do  therefore  assert  boldly,  that 
much  benefit  would  accrue  from  reverting  to  the  old  system,  and  em- 
ploying names  which  have  no  direct  reference  to  the  substances.  I  do 
not  see  any  reason  why  we  should  not  continue  to  call  calomel,  calomel ; 
nor  do  I  see  any  advantage  in  giving  it  any  of  the  numerous  modern 
appellations  supposed  to  indicate  its  chemical  constitution.  I  am  glad 
to  find  that  this  view  of  the  subject  has  the  able  support  of  Dr. 
Sigmond.  He  quotes  Professor  Brande  as  being  of  opinion  that  "it 
is  very  inconvenient  to  alter  pharmaceutical  terms  according  to  the 
changes  in  chemical  nomenclature ;  and  as  physicians  in  practice  have 
not  come  to  accord  in  this  particular,  I  can  see  no  objection  to  the 
term  calomel  for  one  substance,  and  corrosive  suhlimate  for  the  other, 
pharmaceutically  speaking.  It  is  a  subject  of  deep  regret,"  adds  Dr. 
Sigmond,  "  that  the  attempt  should  be  made,  because  it  never  can  be 
successful;  for  some  chemists  will  call  calomel  jorotochloridcj  others 
cMoride,  and  some  denominate  ^vM[\mdXQ  percJiloride,  others  deutocJdo- 
ride,  and  others  again,  as  does  the  Royal  college  oiVYijsicmns, bichloride" 
How  remarkably  corroborated  is  the  truth  of  these  remarks  by  the  fact. 


Ji<fc  CLINICAL   MEDICINE. 

that  at  present  nearly  all  chemists  agree  in  considering  calomel  a  suh- 
chloride  J  and  corrosive  sublimate  a  chloride  of  mercury  ? 

What  is  the  use  of  a  name  ?  To  designate  a  thing — to  point  out 
any  substance,  so  that  when  we  call  for  it  we  may  get  it,  and  nothing 
else.  This  is  all  that  is  necessary.  When  you  tax  a  name  beyond  this, 
you  exceed  the  limits  of  ordinary  language,  and  demand  too  much. 
The  old  names  for  our  medicines  are  not  inferior,  in  this  respect  to  the 
modem  ones  imposed  on  us  by  chemists.  Tartar  emetic  is  a  good  and 
significant  name,  and  yet  I  perceive  it  has  been  altered  several  times 
before,  and  again  in  the  last  edition  of  the  London  Pharmacopoeia. 
Why  is  it  that  the  preparation  of  bismuth  used  in  pyrosis  has  been 
three  times  changed  in  my  own  memory  ?  What  alterations  have  not 
the  carbonates  of  iron  and  of  alkaHes  undergone  ?  As  for  Fowler's 
solution,  corrosive  sublimate,  Mindererus'  spirit,  and  ^thiop's  mineral 
(all  good  standard  names),  they  are  now  nearly  extinct,  and  have  been 
superseded  by  a  new  generation  likely  to  prove  as  unstable  as  their 
predecessors.  Many  other  substances  have  undergone  the  same  fate. 
Where  will  the  revolution  stop  ?  Indeed  we  seem,  at  the  present  mo- 
ment, as  far  removed  as  ever  from  the  establishment  of  a  stable  system 
of  chemical  names.  The  progress  of  investigation  discloses  almost 
daily  new  views  of  the  mutual  relations  between  the  elements  consti- 
tuting compound  bodies ;  the  atoms  associated  together  are  divided  and 
subdivided  into  new  groups,  and,  consequently,  the  symbohcal  repre- 
sentation of  every  compound  assumes  a  new  configuration,  and  is  sub- 
divided by  brackets,  altering  their  places  with  each  successive  advance 
of  science.  The  labours  of  Bornsdorff  and  Hare  already  threaten  the 
nomenclature  of  Berzelius,  and  the  chlorure  platinosopotassique  of  the 
latter,  now  considered  as  a  compound  of  chloroplatinous  acid  and  the 
chlorobase  of  potassium,  must  then  be  called  chloroplatinite  of 
potassium. 

In  a  retrospect  of  the  progress  of  chemistry  for  the  years  1846-7, 
published  by  Mr.  SuUivan  in  the  number  of  the  Dublin  Quarterly 
Journal  of  Medical  Science  for  February,  1848,  at  page  243  is  the 
following  paragraph  : — "Thus,  NaO,  SO3  «  lOxiq,  would  be  natan-afin- 
wasue;  'i'^^0,Wd,'^0^-\-%^<hj\,^ov\A\iQJenatan-alan-a]iun-weso;  NH4 
O,  AI2  O3,  4S03-|-24Aq,  one  of  the  most  complicated  formulae,  would 
be  atolan-telmin-ojafin-weso,  a  word  which  is  certainly  longer  than 
ammonia-alum,  but  shorter  than  crystallized  sulphate  of  ammonia  and 
alumina,  and  even  than  the  formula,  which  has  eighteen  syllables  when 
read,  while  the  new  name  has  only  ten."  If  such  names  be  ever  intro- 
duced into  our  Pharmacopoeia,  I  fear  we  must  get  over  some  of  the 
aborigenes  of  the  South  Sea  Islands  to  teach  us  how  to  pronounce 
them  ! 


CHEMICAL   KOMENCLATrRE.  25 

If  chemical  names  are  still  to  be  formed  with  the  view  of  expressing 
chemical  composition,,  there  is  no  end  to  the  complication  and  length 
at  which  they  must  arrive.  If  they  express  composition,  it  is  worse 
than  useless,  were  they  to  do  so  incompletely.  A  name  whese  struc- 
ture designates  the  nature  of  the  thing  named,  must,  in  chemistry,  to 
be  serviceable,  designate  it  with  perfect  accuracy.  Professor  Kane  has 
analyzed,  in  one  of  his  very  able  papers,  a  crystalline  substance  ob- 
tained by  boiling  the  white  ammonia  subnitrate  of  mercury  with  solu- 
tion of  ammonia.  Suppose  this  substance  to  be  introduced  into  the 
Pharmacopoeia,  how  can  it  be  named  in  conformity  with  the  principle 
which  attempts  to  make  each  name  expressive  of  the  composition  of 
the  matter  named  ?  its  composition  is  stated  by  Professor  Kane  to  be — 
one  atom  of  nitrate  of  the  oxide  of  mercury,  plus  two  atoms  of  oxide 
of  mercury,  plus  one  atom  of  amide  of  mercury,  plus  two  atoms  of 
the  nitrate  of  the  oxide  of  ammonium,  plus  two  atoms  of  the  oxide  of 
hydrogen.  Even  if  the  ingenuity  of  chemists  had  surmounted  the 
difficulty  of  inventing  a  name  capable  of  expressing  the  nature,  num- 
ber, and  mode  of  aggregation  of  the  above  elementary  atoms,  is  it 
probable  that  a  name,  so  gifted,  would  be  of  a  length  manageable  by 
either  the  tongue  or  the  memory?  Is  it  certain  that  future  experiments 
may  not  unfold  new  views  concerning  the  arrangement  of  the  consti- 
tuent atoms,  and  thus  nullify  the  old,  by  requiring  the  adoption  of  a 
new  designation  ? 

The  following  apposite  remarks  on  this  subject  are  extracted  from  a 
review  of  Dr.  Gregory^'s  Chemistry,  in  the  London  Medical  Gazette  for 
October  3rd,  1845.  The  reviewer,  in  noticing  some  of  the  new  or- 
ganic substances  described,  and  the  metamorphoses  which  they  undergo, 
says,  ^'  Clever  as  this  exposition  is,  we  fear  that  it  will  be  as  unintelli- 
gible as  Coptic  or  Sanscrit,  not  only  to  practitioners,  but  to  the  pre- 
sent race  of  students,  who  are  apt  to  look  very  closely  to  what  concerns 
them  in  their  examinations.  There  is,  however,  this  consolatory  re- 
flection, that  the  examiners  would  themselves  have  to  go  to  school  again 
before  they  attempted  to  ask  questions  upon  one  half  of  the  subjects 
introduced  into  this  volume  on  Organic  Chemistry.  Without  intending 
any  disrespect  to  the  examhiers  of  the  University  of  London,  or  the 
Apothecaries^  Society,  we  do  not  think  that  there  is  one  among  the 
whole  body  w^ho  could  decribe  ofP-hand  the  symbohcal  differences  be- 
tween the  Oxalate  and  Oxamate  of  the  Oxide  of  Methyle,  (p.  397),  the 
composition  of  chloro-phrenisic  acid  (511),  or  the  construction  of  cin- 
namic  acid  from  cinnamyle  !  The  candidates  for  the  diploma  are  there- 
fore safe  for  the  present. 

"  We  agree  with  the  author,  that  scientific  chemistry  has  been  too 
much  neglected  in  this  country ;  but  it  is  questionable  whether  a  taste 


26  CLINICAE    MEDICINE. 

for  it  can  be  revived  by  the  introduction  of  a  cumbrous  nomenclature 
founded  on  hypothetical  postulates — whether,  indeed,  the  student  will 
not  be  discouraged  by  finding  the  properties  of  substances  drowned  in 
symbols  and  formulae.  Tliis  appears  to  us  to  be  a  defect  in  the  work 
before  us.  We  turn  over  the  pages,  and  we  continually  meet  with  rows 
of  symbols  and  formulae,  as  well  as  names,  with  which  it  would  be  a 
matter  of  despair  to  charge  the  memory.  Dr.  Prout  long  since  entered 
a  protest  against  the  barbarism  of  Liebig  and  Wohler^s  new  terms,  and 
he  expresses  himself  by  no  means  satisfied  that  the  doctrines  on  wliich 
they  are  founded  are  satisfactorily  established.  The  remarks  on  this 
subject  made  by  another  eminent  English  chemist  (Brande)  are  so  ap- 
posite, that  w^e  shall  here  quote  them.  '  The  nomenclature  which, 
among  the  continental  chemists,  is  creeping  into  organic  chemistry, 
cannot,  I  think,  be  too  strongly  protested  against  by  aU  who  are  en- 
gaged in  teaching  chemistry.  Neither  arrangement  nor  nomenclature 
are  of  much  importance  to  those  who  have  advanced  far  into,  and  are 
familiar  with,  the  more  complicated  details  of  the  science ;  but  to  the 
student,  the  capricious  and  hypothetical  terms  which  are  in  vogue  are 
either  unintelligible,  or,  what  is  worse,  are  calculated  to  mislead  and 
embarrass.' '' 

In  order  to  exemplify  how  much  physiology  and  pathology  are  in- 
debted to  the  researches  of  chemists,  I  beg  to  quote  at  length  from  the 
Quarterly/  Review^  June,  1842,  (p.  99,  and  p.  121.) 

"  Professor  Liebig  applies  the  name  of  metamorjohosis  to  those  che- 
mical actions  in  which  a  given  compound,  by  the  presence  of  a  peculiar 
substance,  is  made,  to  resolve  itseK  into  two  or  more  compounds,  e,  g. 
sugar  by  presence  of  yest,  into  alchohol  and  carbonic  acid. 

"  Now,  putrifying  animal  matters  wiU  cause  sugar  to  ferment  as  well 
as  yest :  explanation,  the  ferment  or  exciting  body  is  invariably  a  sub- 
stance in  an  active  state  of  decomposition,  and  therefore  its  particles  in 
motion ;  this  motion  is  communicated  to  the  particles  of  the  body  to  be 
metamorphosed,  and  is  sufiicient  to  overturn  their  very  unstable  equili- 
brium, and  to  cause  the  formation  of  new  and  more  stable  compounds. 
Liebig  explains  the  action  of  certain  medicines  and  poisons  on  the 
human  body  in  the  same  way — thus  there  are  many  medicines  and  poi- 
sons wliich  produce  a  very  marked  effect  without  their  elements  taking 
a  direct  share  in  the  changes  which  ensue ;  those  bodies  originate,  as  it 
were,  in  action,  wliich  is  subsequently  propagated  from  particle  to  par- 
ticle ;  they  are  uniformly  substances  in  a  state  of  change,  and  appear 
to  act  on  the  blood,  as  yest  does  on  a  solution  of  sugar.  In  tins  class 
appear  miasms,  contagions,  and  the  similar  sausage  poison  of  Wiirtem- 
berg ;  the  latter  is  an  excellent  example.  Sausages,  made  in  a  peculiar 
way,  are  much  used  in  that  comitry ;  when  ill-prepared  they  become 


27 

poisonous,  and  their  effects  are  invariably  fatal :  the  patient  gradually 
dries  up  into  a  sort  of  mummy,  and  after  weeks  or  months  of  misery, 
death  closes  the  scene ;  but  there  is  no  poisonous  substance  to  be  de- 
tected in  the  sausage.  It  is,  according  to  Liebig,  in  a  peculiar  state 
of  fermentation,  which  is  not  checked  by  the  action  of  the  stomach, 
and  which,  unfortunately,  is  communicated  to  the  blood  ;  it  never 
ceases  until  every  part  capable  of  solution  has  been  destroyed,  and 
death  of  course  must  follow.  Miasras  and  contagions  act  on  the  very 
same  principle,  and  the  reason  that  all  are  not  affected  by  them  seems 
to  be,  that  they  require  the  presence  of  a  peculiar  compound  in  the 
blood,  wliich  enters  into  decomposition,  and  when  the  whole  of  this 
peculiar  matter  is  destroyed,  the  disease  disappears.  If  there  be  much 
such  matter  the  case  is  severe j  if  little,  the  case  is  mild ;  and  appa- 
rently in  many  contagious  diseases,  the  peculiar  decomposable  matter 
once  destroyed  can  never  he  renewed,  so  that  these  diseases  occur  hut 
once" 

Such  is  Professor  Liebig^  s  theory  of  poisoning  and  contagion — a 
theory  which,  though  it  comes  to  us  recommended  by  the  abilities  of 
the  first  organic  chemist  of  the  age,  and  sanctioned  by  his  anonymous 
but  able  reviewer  in  the  Quarterly,  can  nevertheless  be  easily  proved  to 
rest  on  almost  as  many  assumed  as  proven  facts.  Thus  how  can  Liebig 
so  positively  assert  that  there  is  no  poisonous  substance  in  the  fatal  sau- 
sages ?  True  it  is  that  no  chemist  has  yet  insulated  such  a  substance ; 
but  Liebig  knows  better  than  any  one  else  how  profoundly  concealed 
any  particular  animal  principle  may  be  by  being  mixed  with  a  great  va- 
riety of  other  animal  principles.  Thus  how  long  did  sugar,  in  the 
blood  of  diabetic  patients,  elude  the  searches  of  chemists  ?  and  yet 
they  were  looking  for  a  principle  with  whose  chemical  qualities  they 
were  already  accurately  acquainted.  How  much  more  difficult  of  detection 
must  the  poisonous  principle  be,  wliich  exists  in  so  compound  a  body  as 
a  Wiirtemberg  sausage  ?  Besides,  what  chemist  was  ever  sure  that  he 
was  actually  analyzing  a  poisonous  sausage  ?  Here  a  special  difficulty 
lies,  for  hitherto  there  has  been  discovered  no  a  priori  method  of  dis- 
tinguishing a  poisonous  from  a  wholesome  sausage  until  both  have  been 
eaten,  that  is  too  late  for  analysis.  How  long  has  the  poisonous 
quality  of  ergot  of  rye  been  known  ?  and  yet  the  principle  to  which 
its  effects  are  owing,  though  often  sought,  has  been  only  lately 
insulated. 

It  is  obvious,  therefore,  that  Professor  Liebig^s  main  example  of  his 
new  pathological  explanation  is  not  by  any  means  proven,  and  conse- 
quently it  is  unnecessary  to  follow  him  into  the  regions  of  fancy  where 
he  has  been  enticed  by  a  specious  and  seductive  analogy.  Pathology 
will  cease  to  be  a  science  when  the  study  of  facts  gives  place  to  such 


^o  CLINICAL   MEDICINE. 

reveries  as  the  above-cited  passage  contains — relative  to  miasms,  conta- 
gions, mild  cases,  severe  cases,  diseases  occurring  but  once  in  life,  &c., 
&c.,  &c.  And  yet  I  am  sorry  to  say  that  one  of  our  most  distinguished 
lecturers.  Dr.  Watson,  has,  in  his  pubHshed  lectures  on  the  Practice  of 
Physic  (volume  2,  p.  667,  1st  edition),  fully  adopted  these  opmions. 

In  order  to  give  the  reader  some  idea  of  what  Dr.  Watson  considers 
to  be  "  distinct  conceptions"  and  "  li^/its  supplied  hy  a  theory"  I  beg 
leave  to  quote  from  the  Doctor's  lecture  the  following  paragraphs  : — 

"  Moreover,  the  light  supplied  by  tliis  theory  gives  distinctness  to 
our  conceptions  respecting  certain  deviations  from  the  regular  course 
and  type  of  these  diseases ;  which  deviations  are  not  uncommon. 

"  Thus  the  symptoms  which  precede  and  usher  in  the  eruption  are 
sometimes  slow,  halting,  and  irregular  in  their  progress  ;  appear,  and 
then  recede,  and  reappear,  so  that  we  are  in  doubt  what  is  about  to 
happen,  until  at  length  the  disease  declares  itself  in  its  decided  and 
authentic  form. 

''We  may  suppose  this  to  depend  upon  some  tardiness  or  inter- 
ruption of  the  process,  whereby  the  virus  is  (to  use  the  ancient  term) 
concocted. 

"  Again,  the  series  or  combination  of  symptoms  that  mark  the  spe- 
cific disease  is  sometimes,  as  I  stated  before,  incomplete.  We  have  the 
eruption  of  measles  without  the  catarrhal  symptoms ;  the  sore  throat 
without  the  rash,  of  scarlet  fever.  And  experience  has  found  that, 
where  the  malady  is  thus  imperfectly  developed,  the  protection  it  con- 
fers against  its  own  recurrence  is  also  incomplete.  To  explain  this 
double  failure  we  may  reasonably  infer  a  corresponding  defect  in  the 
series  of  changes  which  the  poison  tends  to  produce  in  the  mass  of  the 
blood. . 

"  Glandular  enlargements  and  chronic  abscesses  are  frequent  sequelcB 
of  these  exa|ithematous  disorders.  They  may  be  considered  to  repre- 
sent the  dregs  of  the  reproduced  virus,  which  has  been  imperfectly 
eliminated  from  the  system  by  the  usual  channels." 

Yery  few  observations  are  called  for  by  these  surmises  of  Dr.  Watson; 
and  certainly  the  learned  Doctor  is  rather  guarded  in  liis  expressions, 
thus  admitting  that  though  he  has  given  his  adhesion  to  Liebig's  theory, 
yet  he  seems  to  view  the  deductions  to  wliich  it  leads  with  considerable 
distrust.  Indeed  it  is  diificult  to  rest  satisfied  with  reasoning  which 
not  only  assumes  gratuitously  a  certain  thing  to  be  the  cause  of  a  cer- 
tain effect,  but  considers  it  a  corroboration  of  that  assumption,  that 
whereas  the  effect  is  irregular  in  its  progress,  we  may  suppose  the  cause 
is  so  likewise. 

It  is  still  a  greater  triumph  of  logic  to  infer  that,  because  a  disease 
is  incomplete,  we  gain  anytldng  towards  the  establishment  of  the  true 


nature  of  its  cause,  by  saying  that  we  may  reasonably  infer  a  corre- 
sponding defect  exists  in  the  cause  itself.  To  me  the  whole  line  of 
argument  appears  delusive ;  and  as  to  the  last  paragraph,  concerning 
glandular  enlargement  and  chronic  abscesses,  it  seems  that  Dr.  Watson's 
conclusion  involves  a  contradiction,  for  he  attributes  to  the  virus  itself, 
and  that  by  virtue  of  its  chemical  action,  the  production  of  several 
exanthematous  diseases,  each  specifically  distinct,  and  indeed  as  differ- 
ent from  each  other  as  an  acid  from  an  alkali,  while  to  the  dregs  of  the 
reproduced  virus,  he  attributes  sequelae — those  glandular  enlargements 
and  clironic  abscesses  which  so  frequently  appear  after  small  pox,  scar- 
latina, or  the  measles.  According  to  this  hypothesis,  three  different 
animal  poisons,  all  acting  chemically,  produce  at  first  three  different 
diseases,  and  at  last  the  same  disease.  With  regard  to  this  hypothesis, 
I  may  further  remark,  that  when  a  brewer  takes  a  certain  quantity  of 
sweet  wort,  puts  it  in  a  vessel,  and  adds  a  given  portion  of  yeast  ^  to 
it,  he  knows  that  if  he  simultaneously  fills  in  the  same  way  fifty  similar 
vessels,  the  process  of  fermentation  will  produce  in  each  thirty  times  as 
much  yeast  as  was  originally  added  to  the  wort.  But  when  the  virus 
of  small  pox  is  introduced  into  the  blood  of  fifty  individuals,  is  a  mul- 
tiplication of  the  small  pox  matter  thus  proportioned  to  the  quantity  of 
blood  in  each  ?  It  certainly  is  not ;  a  fact  conceded  by  the  supporters 
of  Liebig's  hypothesis,  but  which  they  try  to  evade  by  saying  that  the 
particles  of  the  blood  which  are  susceptible  of  tliis  particular  de- 
composition and  metamorphosis  exist  in  different  proportions  in  dif- 
ferent individuals. 

This  method  of  ratiocination  is  as  inconclusive  as  it  is  novel,  and  may 
be  aptly  termed,  arguing  not  in  but  outside  of  a  circle. 

The  following  quotation,  taken  from  the  Provincial  Medical  Journal, 
contains  a  condensed  but  very  accurate  analysis  of  Liebig's  theory  of 
heat,  and  the  pathological  inferences  which  necessarily  appear  to  flow 
from  it : — 

"  The  carbon  and  hydrogen  of  food,  in  being  converted  by  oxygen 
into  carbonic  acid  and  water,  must  give  out  as  much  heat  as  if  they 
were  burned  in  the  open  air.  The  only  difference  is,  that  this  heat  is 
spread  over  unequal  spaces  of  time ;  but  the  actual  amount  is  always 
the  same.  The  temperature  of  the  human  body  is  the  same  in  the 
torrid  as  in  the  frigid  zone.  But  as  the  body  may  be  considered  in  the 
light  of  a  heated  vessel,  which  cools  with  an  accelerated  rapidity  the 
colder  the  surrounding  medium,  it  is  obvious  that  the  fuel  necessary  to 
retain  its  heat  must  vary  in  different  climates.      Thus,  less  heat  is 

*  We  are  glad  to  find  Dr.  Watson  adhering  to  the  old  spelling  of  this  word.  He  spells 
it  as  De  Foe  spells  it  in  his  Robinson  Crusoe  ;  this  authority  is  probably  as  good  as  any 
the  writer  in  the  Qimrterhj  Review  could  bring  forward  in  support  of  his  yest. 


30  CLINICAL    MEDICINE. 

necessary  in  Palermo,  where  the  temperature  of  the  air  is  that  of  the 
human  body,  than  in  tlie  polar  regions,  where  it  is  about  90^  lower. 
In  the  animal  body,  the  food  is  the  fuel ;  and,  by  a  proper  supply  of 
oxygen,  we  obtain  the  food  given  out  during  its  combustion  in  winter. 
When  we  take  exercise  in  a  cold  atmosphere,  we  respire  a  greater 
amount  of  oxygen,  which  implies  a  more  abundant  supply  of  carbon  in 
the  food ;  and,  by  taking  this  food,  we  form  the  most  efficient  protec- 
tion against  the  cold.  A  starving  man  is  soon  frozen  to  death :  and 
every  one  knows  that  the  animah  of  prey  of  the  arctic  regions  are  far 
more  voracious  than  those  of  the  torrid  zone/^  Our  clothing  is  merely 
an  equivalent  for  food ;  and  the  more  warmly  we  are  clothed  the  less 
food  we  require.  Were  we  to  go  destitute  of  clothes  like  certain 
savage  tribes — or  if,  in  hunting  or  fishing,  we  were  exposed  to  the  same 
degree  of  cold  as  the  Samoyedes — we  could,  with  ease  consume  lOlbs. 
of  flesh,  and,  perhaps,  a  dozen  tallow  candles  into  the  bargain,  as 
warmly  clad  travellers  have  related,  with  astonishment  of  those  people. 
Then  could  we  take  the  same  quantity  of  brandy  or  blubber  of  fish 
without  bad  effects,  and  learn  to  appreciate  the  delicacy  of  train  oil. 

"We  thus  perceive  an  explanation  of  the  apparently  anomalous 
habits  of  different  nations.  The  maccaroni  of  the  Italian,  and  the  train 
oil  of  the  Greenlander  and  the  Russian,  are  not  adventitious  freaks  of 
taste,  but  necessary  articles  fitted  to  administer  to  their  comfort  in  the 
climates  in  which  they  have  been  born.  The  colder  the  region,  the 
more  combustible  must  the  food  be." 

It  is,  I  must  confess,  quite  new  to  me  that  our  clothing  is  merely  an 
equivalent  for  food,  and  the  more  warmly  we  are  clothed  the  less  food 
we  require.  Take  the  well  clad  and  warmly  clothed  country  squire, 
and  compare  the  quantity  of  food  he  devours  with  that  which  is  con- 
sumed by  his  ragged  labourers,  and  it  may  be  asserted  that  the  balance 
will  be  as  much  in  favour  of  the  squire's  food  as  of  his  raiment.  The 
voracious  Samoyedes  referred  to,  however  barbarous  in  their  manners, 
are  an  extraordinarily  warmly  clothed  race,  and  the  semi-putrid  fat  and 

*  I  cannot  guess  how  every  body  comes  to  know  all  this ;  for  my  own  part,  I 
think  it  may  be  maintained  that  a  Bengal  tiger,  or  Cape  hyaena,  requires,  in  pro- 
portion to  its  size,  quite  as  abundant  rations  as  any  of  the  arctic  carnivora  ;  and  as 
to  the  vultures  of  Hindostan  and  Persia,  where  on  earth,  in  air,  or  in  water,  can 
be  found  such  gluttons  ?  Neither  do  I  think  that  any  one  (not  to  say  every  body) 
would  be  prudent  in  counting  on  the  abstinence  of  a  shark,  even  within  the  tropics ! 
Although  religious  ordinances  prevent  the  Hindoos  from  eating  beef,  yet  both  they 
and  the  Arabs  occasionally  devour  mutton  in  astonishing  quantities.  Those  who 
ride  over  the  Pampas,  in  South  America,  at  the  rate  of  100  miles  a  day  exposed  to 
a  burning  sun,  subsist  entirely  on  boiled  beef  and  water,  without  a  particle  of  vege- 
table food  of  any  kind,  and  yet  they  attain  to  an  extraordinary  cmidition,  and  capa- 
bility of  enduring  violent  and  long  continued  exertion.  Liebig's  theory  must  be 
very  ductile,  if  it  can  explain  how  it  happens  tliat  an  exclusively  animal  diet  agrees 
with  man  quite  as  well  at  the  equator  as  within  the  arctic  circle. 


LIEBIG  S    THEORY  OF    HEAT.  31 

blubber  of  whales,  agrees  with  the  stomach  of  the  Laplander  as  well  in 
the  heat  of  summer  as  in  winter.  In  the  arctic  and  cold  regions  of  the 
earth  man  is  driven  by  necessity  to  subsist  on  animal  food,  wliich  is 
supplied  to  him  by  the  unfrozen  depths  of  the  ocean,  for  in  those 
inhospitable  regions  vegetable  life  is  almost  a  stranger,  and  therefore 
it  is  that  the  Laplander,  the  Greenlander,  and  Samoyede  subsist  almost 
exclusively  on  animal  food.  In  the  expeditions  of  Franklin,  Parry,  and 
Koss,  our  countrymen  braved  all  the  rigours  of  an  arctic  winter  on  the 
same  food  which  they  were  in  the  habit  of  consuming  in  milder 
climates ;  and  if  it  be  true,  as  stated  in  the  above  passage,  that  in  the 
animal  body  the  food  is  the  fuel,  and,  by  a  proper  supply  of  food,  we 
obtain  the  oxygen  given  out  by  its  combustion  in  winter :  if  this  be 
true,  it  is  strange  that  there  is  no  record  of  its  being  found  necessary  to 
give  our  sailors  more  food  during  the  extreme  cold  than  at  other 
periods. 

Facts  are  wholly  inconsistent  with  many  of  Liebig^s  allegations.  All 
hunting  tribes  of  mankind,  whether  in  northern,  temperate,  or  tropical 
regions,  subsist  cliiefly  on  animal  food.  This  is  true  of  the  North  and 
South  American  Indians,  and  it  is  true  of  the  Hottentots,  and  indeed 
our  travellers  relate  prodigies  of  gluttony  enacted  by  the  latter,  for 
when,  after  a  long  fast,  they  suddenly  obtain  abundance  of  game,  they 
wiU  sit  up  the  whole  night  occupied  in  cooking  and  devouring  steak 
after  steak  unaccompanied  by  a  morsel  of  vegetable  food,  and  at  such 
times,  so  indefatigable  are  they  in  the  business  of  eating,  that  the  party 
which  over  night  had  tightened  their  famine  girdles  to  the  last  hole, 
have  enormously  distended  abdomens  on  the  following  morning, — this, 
too,  in  the  heat  of  Africa,  where  certainly  no  additional  fuel  was  re- 
quired for  supporting  the  animal  temperature.  If  Liebig's  theory  be 
correct,  that  animal  food  is  peculiarly  adapted  to  cold  climates  how  comes 
it  that  the  most  voracious  carnivorous  animals  abound  in  the  hottest  re- 
gions of  the  earth.  The  Bengal  tiger,  and  the  African  Hon,  and  the  boa 
constrictor  of  South  America,  together  with  alligators  and  crocodiles  of 
the  Nile,  the  Ganges,  and  the  Oronooko,  aU  subsist  solely  upon  animal 
food ;  and  on  the  other  hand,  among  the  whale  tribe  it  is  observable 
that  they  abound  in  every  variety  of  oceanic  temperature,  where  the  ap- 
propriate animal  food  occurs,  and  the  same  observation  appHes  to  fishes 
in  general.  Take  the  antelope  and  the  gazelle  of  Africa,  wliich  would 
shiver  from  cold  during  the  warmth  of  an  EngHsh  summer,  and  compare 
them  with  the  reindeer,  that  bears  with  impunity,  and  that  for  months 
together,  a  temperature  far  below  zero,  and  how  can  we  explain  the  dif- 
ference by  Liebig's  theory,  for  they  both  subsist  on  vegetable  food  ? 
Facts  such  as  these  are  not  merely  irreconcileable  with,  but  destructive 
of,  that  theory. 


32  CLINICAL   MEDICINE. 

I  would  not  be  understood  here  as  wishing  to  depreciate  any  depart- 
ment of  human  knowledge.  Par  be  it  from  me.  Besides,  the  attempt 
would  be  useless.  But  I  am  anxious  that  you  should  concentrate  all 
your  energies  on  the  proper  objects  of  medical  pursuit,  and  devote  the 
largest  share  of  your  attention  to  those  acquirements  which  will  render 
you  good  practitioners.  I  have  seen  students  led  astray  by  false  notions, 
wasting  half  of  the  time  which  should  be  spent  in  hospital  and  by  the 
sick  bed,  in  wandering  tln-ough  the  fields  on  botanical  excursions,  or 
working  in  the  laboratory,  engaged  in  the  solution  of  some  unimportant 
problem.  Now  this  is  not  what  will  teach  them  to  reheve  suffering,  and 
cure  disease.  When  I  look  round  me,  and  behold  so  many  young  gen- 
tlemen entering  upon  an  honourable'  and  important  profession,  I  feel 
that  my  responsibility  is  great.  I  consider  you  all  as  instruments  of 
good  or  evil,  and  cannot  help  being  conscious  that  I  should  be  guilty  of 
a  great  crime,  did  I  not  use  every  means  in  my  power  to  render  you  able 
and  efficient  practitioners.  The  teacher  of  clinical  medicine,  gentlemen, 
occupies  in  every  nation  a  post  of  heavy  responsibility.  But  when  he 
happens  to  preside  over  the  medical  education  of  those  who  resort  to  the 
wards  of  a  metropolitan  hospital — when  the  metropolis  is  a  British  one, 
and  the  hospital  destined  to  send  forth  annually  practitioners  to  every 
quarter  of  the  globe — to  North  and  South  America,  to  New  Holland,  to 
the  Cape  of  Good  Hope,  to  the  East  and  West  Indies,  and  the  countless 
isles  which,  in  either  hemisphere,  are  visited  by  the  British  flag,  then 
indeed  does  that  teacher  become  himself  an  instrument  of  good  or  evil, 
to  an  extent  which  it  is  fearful  to  contemplate. 

He  who  gives  instruction  to  a  clinical  class  in  Berlin,  Stockholm, 
Yienna  or  Paris,  has  much  to  answer  for,  if  he  discharge  not  his  duties 
with  zeal  and  diligence.  Yet  if  he  fails  to  make  his  pupils  good  practi- 
tioners, their  errors,  however  deplorable,  are  circumscribed  within  com- 
paratively narrow  bounds,  and  limited  in  a  great  degree  to  their  own 
countrymen.  But  the  British  teacher  sits  in  the  centre  of  a  circle  far 
wider  than  Sweden  or  Prussia,  Austria  or  Trance ;  his  pupils  are  to  be 
met  with  practising  in  every  climate,  exercising  their  art  in  almost  every 
habitable  region  of  the  globe  and  dispensing  the  blessings  of  health  to 
all  races  of  mankind : — to  the  hardy  white  setlers  of  Canada,  the  abori- 
ginal red- skins  of  North  jbnerica,  the  Negroes  of  Jamaica,  the  Hotten- 
tots and  Caffres  of  Africa,  and  the  countless  tribes  of  Hindostan. 

In  truth,  gentlemen,  the  British  teacher  of  practical  medicine  exer- 
cises an  influence  without  parallel  in  importance  and  extent,  and  his 
opportunities  of  benefitting  or  injuring  his  fellow  men  are  incalculably 
great.  If  he  neglect  his  duty,  if  he  teach  erroneously,  his  neghgence 
and  his  errors  in  practice  are  multiphed  indefinitely,  by  means  of  those 
whom  he  ought  to  have  better  instructed ;  the  scene  of  his  guilt — for  it 


GENERAL    REMAllKS.  33 

deserves  no  better  name — becomes  fearfully  enlarged,  for  there  is  no 
country  so  remote  that  it  may  not  contribute  victims  to  the  incapacity  of 
jiis  pupils.  But  if,  on  the  contrary,  he  works  with  zeal  and  diligencQ  ; 
if  he  labours  conscientiously  and  perseveringly  in  performing  the  impor- 
tant task  he  has  undertaken,  a  compensation  awaits  him,  to  which 
scarcely  any  member  of  any  profession  can  attain.  Can  any  reward  ex- 
ceed in  value  the  reflection  that  he  has  assisted,  materially  assisted,  in 
imparting  practical  knowledge  to  multitudes  of  enterprising  young 
men,  who,  year  after  year,  leave  our  hospitals  to  engage  in  the  sacred 
duties  of  the  medical  profession,  throughout  the  world  ?  Is  it  not  a 
high  privilege  to  be  enabled  to  combat  death,  and  conquer  disease,  as  it 
were  by  proxy,  in  so  many  different  localities?  Can  man  enjoy  a  purer, 
prouder,  more  gratifying  reflection  ?  Wlien  I  hear  that  a  favourite  pupil 
who  has  acquired  a  solid  stock  of  practical  knowledge  in  this  hospital, 
has  settled  in  any  particular  town  or  district,  I  cannot  help  feeling,  on 
the  part  of  my  colleagues  and  myself,  that  we  have  been  the  hmnblq 
means  of  conferring  a  blessing  on  the  people  entrusted  to  his  care ;  and 
I  cannot  refrain  from  congratulating  myself  upon  holding  a  situation 
which  multiplies  a  .thousand  fold  our  efforts  to  be  useful,  and  enables  us 
to  stretch  forth  our  hands  to  heal  men  of  all  nations  and  languages. 
The  hero  and  the  despot  may  extend  a  sovereignty  over  distant  regions — 
may  exert  an  unlimited  control  over  millions  of  vassals — may  dispense 
honours  and  rewards,  or  inflict  punislnnent  and  death :  they  may,  like 
Alexander,  grieve  at  the  narrow  limits  of  a  conquered  world,  and  sigh 
for  other  scenes  of  glory,  but  they  cannot  chase  away  pain ;  they  cannot 
bid  the  burning  thirst  to  cease,  or  give  back  repose  to  the  sleepless;  they 
cannot  impart  feehng  or  motion  to  the  paralysed,  or  sight  to  the  blind ; 
and  above  all  they  cannot  imitate  that  almost  godlike  function  of  the 
heaHng  art,  by  which  man  is  enabled  to  recal  to  his  fellow-man  reason 
long  banished,  and  restore  i^  society  the  hapless  victim  of  insanity. 

Gentlemen,  the  profession  we  have  embraced  is  the  noblest  that  can 
engage  the  mind  of  man, — when  dihgently  cultivated  and  conscientiously 
practised ;  but  it  requires  great  and  persevering  industry  to  enable  the 
student  to  master  all  the  difficulties  that  beset  his  path.  Feeling  this 
strongly,  I  have  trespassed  perhaps  too  long  on  your  attention ;  but  I 
thought  it  my  duty  to  lay  before  you,  as  fully  as  I  could,  those  views 
which  I  deemed  best  calculated  for  your  adoption  in  the  acquirement  of 
practical  knowledge. 


VOL.  T. 


34 


LECTURE  III. 


ON  THE  PROPER  MODE  OF  STUDYING  PHYSIOLOGY  AND  MORBID  ANATOMY. 

It  is  quite  evident  that  a  knowledge  of  the  functions  and  structure  of 
the  body  in  health  is  essential  to  him  who  undertakes  the  treatment  of 
disease,  and  hence  physiology  has  always  occupied  the  attention  of  phy- 
sicians. Physiology,  however,  may  be  studied  in  very  different  ways, 
and  with  very  different  objects,  and,  until  lately,  aU  those  who  were  en- 
gaged in  the  cultivation  of  this  fascinating  science,  not  contented  with 
observing  the  state  of  the  different  parts  and  tissues  during  health,  the 
nature  and  quahty  of  the  secretions,  the  mechanism  and  operation  of  the 
different  organs,  sought  to  ascend  from  a  knowledge  of  effects  to  an  in- 
vestigation of  causes,  and  after  they  had  classified  the  more  obvious 
phenomena  of  living  bodies,  endeavour  to  ascertain,  if  not  the  very  prin- 
ciple of  hfe,  at  least  those  motions  and  causes  of  motion  which  result 
immediately  from  the  action  of  the  Hving  principle.  Having  thus,  as 
they  conceived,  obtained  a  more  accurate  knowledge  of  the  conditions  of 
health,  they  proceeded  to  form  general  explanations  of  the  causes  of  dis- 
ease, and  frame  general  rules  for  their  removal.  This  method,  appa- 
rently so  philosophical,  and  possessing  so  many  attractions  from  the 
generality  and  simphcity  of  its  application,  has  more  than  any  other  cir- 
cumstance contributed  to  retard  the  progress  of  medicine. 

Gentlemen,  this  is  not  only  an  ancient,  it  is  also  a  modern  evil.  We 
live  among  systems.  It  is  true,  that  the  practice  founded  on  the  me- 
chanical, mathematical,  chemical  and  humoral  physiologies,  has  been 
long  since  abandoned ;  but  the  destructive  system  of  Brown  has  but 
lately  quitted  the  stage,  where  its  place  is  occupied  on  the  Continent  by 
those  of  Broussais  and  Easori,  and  in  Great  Britain  by  the  system  which 
derives  all  diseases  either  from  derangement  of  the  digestive  function, 
or  from  inflammation. 

Physiology  does  not  legitimately  embrace  the  study  of  vital  actions, 
but  merely  aims  at  ascertaining  and  arranging  their  effects.  The  im- 
portant facts,  which  its  study  discloses,  are  perhaps  infinite  in  number. 
As  long  as  we  confine  ourselves  to  these,  we  advance  at  every  step,  and 
all  is  clear  and  intelhgible ;  but  the  moment  we  attempt  to  inquire  into 


THE    STUDY    OF   PHYSIOLOGY.  35 

tlie  causes  and  modes  of  vital  action,  we  begin  to  retrogade,  and  all 
becomes  hypothesis  and  confusion.  Thus,  an  examination  of  the  organ 
of  sight  discovers  a  wonderful  and  beautiful  optical  arrangement,  calcu- 
lated to  form  on  the  retina  a  picture  of  external  objects,  exact  both  in 
its  colouring  and  outline.  The  physiologist,  examining  with  attention 
the  different  parts  of  the  eye,  and  the  laws  of  their  respective  refractions, 
investigates  the  means  by  which  distinct  vision  is  secured  at  different 
distances ;  he  compares  the  human  eye  and  its  appendages  with  that  of 
animals  which  live  in  water,  those  which  soar  into  the  highest  reg-ions  of 
the  atmosphere,  and  those  wliich  burrow  under  ground.  He  considers 
ihe  eye  of  the  mole — feeble  but  protected  against  injuries  likely  to  be 
encountered  in  carrying  on  its  subterraneous  works ;  of  the  eagle — which, 
poised  high  in  mid-air,  selects  its  victim  from  the  distant  pasture ;  of  the 
lly — whose  microscopic  organ,  with  a  range  of  vision  scarcely  exceeding 
the  limits  of  contact,  distinguishes  objects  the  most  minute ;  and  in  all  he 
finds  variations  in  the  optical  instrument  at  once  curious  and  intelligi- 
ble. But  when  he  endeavours  to  advance  further  in  his  inquiry,  and 
tries  to  explain  how  an  image  painted  on  the  retina,  produces  vision, 
whether  by  the  means  of  undulations  arising  from  the  rays  of  light  and 
propagated  along  the  optic  nerve  to  the  brain,  or  whether  because  the 
retina  is  a  nervous  expansion,  higlily  organised  and  framed,  so  as  to  feel 
the  coloured  image  painted  on  it ;  he  is  at  once  arrested  in  his  progress 
by  the  barrier  wliich  is  everywhere  interposed  between  physical  and  vital 
actions — between  the  mechanism  of  the  organs  of  sense  and  the  mode  in 
which  they  produce  ideas  between  body  and  mind. 

But  has  he,  therefore,  gained  no  real  knowledge  appHcable  to  practi- 
cal purposes,  or  has  liis  time  been  merely  spent  in  a  pleasing  but  useless 
study  ?  By  no  means ; — being  acquainted  with  the  mechanism  and 
arrangement  of  the  optical  instrument,  he  is  often  enabled  to  remedy  its 
accidental  derangements.  By  means  of  a  concave  glass  he  corrects  a 
too  speedy,  by  a  convex  a  too  tardy,  concentration  of  the  rays  of  light. 
When  the  crystalline  lens  becomes  opaque,  liis  knowledge  of  its  connex- 
ions, nature,  and  position  enables  liim  either  to  remove  it  altogether, 
displace  it  from  the  axis  of  vision,  or  to  promote  its  absorption,  and,  in 
order  to  effect  the  latter  purpose,  he  mechanically  irritates  it,  knowing 
by  experience,  that  after  such  an  irritation,  the  process  of  absorption 
commences,  although  he  is  quite  ignorant  of  the  connexion  between 
mechanical  irritation  and  tliis  vital  process.  He  who  inquires  into  the 
physiology  of  the  brain  and  spinal  marrow  can  never  discover  the  natm-e 
of  nervous  influence,  or  the  manner  in  which  pressure  on  -  these  organs 
destroys,  or  irritation  deranges,  the  motions  of  the  voluntary  muscles, 
and  yet  the  entire  treatment  of  cerebral  or  spinal  diseases,  whether  spon- 
taneous, or  from  the  effects  of  injury,  is  grounded  on  a  knowledge  of 


36  CLINICAL    MEDICINE. 

this  physical  fact :  without  it  we  could  not  estimate  tlie  value  or  effects 
of  morbid  changes  in  the  brain  or  spinal  marrow.  On  this  reposes  the 
rationale  of  the  treatment  of  all  convulsive^,  paralytic^  and  apoplectic 
affections. 

Although  we  know  not  the  manner  in  which  the  eighth  pair  of  nerves 
superintends  the  respiratory  process,  although  we  understand  not  how 
the  plirenic  nerves  influence  the  motion  of  the  diapliragm,  yet  a  know- 
ledge of  these  facts  led  to  a  means  of  reHef  for  spasmodic  asthma,  and  to 
the  recovery  of  persons  apparently  asphyxiated,  by  means  of  the  Galvanic 
stimulus  passed  along  the  course  of  these  nerves.  Knowing  that  some 
of  the  nerves,  distributed  to  the  face,  are  destined  for  sensation,  while 
others  serve  for  muscular  motion :  in  cases  of  tic- douloureux  we  divide 
the  sentient  and  not  the  motive  nerves.  In  these,  and  a  thousand  other 
instances,  physical  physiology  supplies  us  with  information  at  once  in- 
teresting and  practical ;  it  would  be  still  easier  to  prove,  as  in  the  cases 
of  Brown  and  Broussais,  that  vital  physiology,  by  involving  us  in  the 
discussion  of  subjects  beyond  the  powers  of  our  reason,  never  fails  to 
entangle  its  votaries  in  a  labyrinth,  amidst  whose  mazes  they  move  with- 
out progressing,  and  consume  in  idle  speculations  that  time  and  labour 
they  ought  to  spend  in  the  acquisition  of  useful  knowledge.  But  I 
trust  the  period  has  at  length  arrived  when  this  error  will  be  avoided ; 
for,  on  the  whole,  it  must  be  confessed,  that  in  consequence  of  a  wrong 
method  of  studying,  and  a  misconception  of  the  true  objects  of  physio- 
logy, this  science  has  in  many  instances  retarded  the  progress  of  practical 
medicine. 

Let  us  next  consider  the  connexion  of  morbid  anatomy  with  practical 
medicine.  Many  have  mistaken  the  end  and  object  of  morbid  anatomy, 
and  there  are  not  wanting  some  who  even  deny  its  utility,  wliile  others 
again,  in  their  zeal  for  its  improvement,  have  endeavoured  to  extend  its 
limits  so  as  to  make  it  comprehend  and  embrace  in  the  explanations  it 
affords  aU  the  phenomena  of  disease.  It  is  not  easy  to  determine  which 
of  these  parties  has  most  injured  the  cause  of  practical  medicine.  Morbid 
anatomy  comprehends  not  merely  decided  and  permanent  structural 
alteration,  but  embraces,  so  far  as  they  are  capable  of  being  detected, 
even  temporary  physical  changes  in  internal  organs.  In  order  justly  to 
estimate  its  importance,  we  should  recollect  that  the  first  alteration  in 
the  texture  of  a  part  is  not  the  cause  but  the  consequence  of  disease,  for 
in  every  healthy  organ  the  texture  is  natural,  and  as  every  change  of 
texture  is  produced  in  consequence  of  derangement  in  the  vital  action  of 
the  vascular  system  of  the  part,  it  is  obvious  that  structural  alteration 
must  in  the  first  instance  be  always  produced  by  functional  derangement. 
Thus  the  physical  alterations  which  attend  external  inflammation,  the  tu- 
mefaction, the  heat,  the  redness  are  not  the  causes  but  the  consequences 


THE    STUDY    OF    MORBID    ANATOMY.  37 

of  disease.  But  in  tlms  reducing  them  to  the  rank  of  symptoms^  do  we 
diminish  their  importance  ?  Certainly  not.  For  being  immediately 
connected^  as  effects,  with  the  primary  cause,  they  prove  the  most  useful 
of  all  symptoms,  in  enabhng  us  to  ascertain  the  seat  and  progress  of 
diseased  action.  In  this  respect  they  possess  a  manifest  advantage  over 
the  general  or  constitutional  symptoms.  Thus,  in  cases  of  spontaneous 
gangrene,  phlegmonous  inflammation,  or  erysipelas,  what  practitioner 
would  be  contented  to  draw  his  indications  from  the  general  symptoms, 
disregarding  the  appearance  of  the  affected  part  ?  And  yet  tliis  is  exactly 
what  those  persons  do,  who  refuse  the  aid  of  morbid  anatomy  in  the 
treatment  of  internal  disease. 

In  external  diseases  most  of  the  physical  changes  in  the  affected  part 
can  be  at  once  recognised;  their  diagnosis  is  therefore  comparatively 
easy,  and  their  treatment  well  established.  In  internal  diseases  the  case 
is  widely  different,  the  physical  alterations  are  here  beyond  the  cognizance 
of  our  senses ;  and,  in  order  to  ascertain  their  nature  and  situation,  we 
must  carefully  compare  the  morbid  appearances  of  internal  organs,  as 
revealed  to  us  by  dissection,  with  the  symptoms  during  life. 

Although  alteration  of  structure  is  in  the  first  instance  produced  by  a 
disease  in  the  vital  action  of  the  part,  yet  this  structural  alteration  may 
itself  become  a  new  cause  of  mischief.  Thus  the  vascular  system  of  the 
lungs,  from  some  unknown  cause,  assumes  such  a  change  of  action  as 
produces  a  deposition  into  the  pulmonary  texture  of  various  fluid  and 
solid  products,  by  which  the  entrance  of  the  air  into  its  vesicles  is  pre- 
vented, and  the  respiratory  function,  one  of  the  most  important  of  the 
body,  is  thus  considerably  deranged.  Again,  whatever  be  the  original 
vital  derangement  which  causes  scirrhus  of  the  pylorus,  the  obstruction 
thus  formed  is  a  secondary  cause  of  new  and  important  symptoms. 

Another  consideration,  which  enhances  the  value  of  morbid  anatomy, 
arises  from  the  fact,  that  when  diseased  action  fixes  itself  in  any  part  of 
the  body,  whether  external  or  internal,  and  there  gives  rise  to  physical 
alterations,  experience  teaches  us,  that  the  progress  of  the  disease  may 
be  often  arrested  by  removing  its  effects.  Thus,  to  recur  to  the  example 
of  external  inflammation,  the  redness,  the  swelling,  the  heat  of  the  part 
are  but  symptoms,  and  yet  we  find  great  benefit  from  the  apphcations  of 
remedies  capable  of  diminishing  them :  hence  we  leech,  and  apply  cold 
lotions,  &c. 

From  all  these  considerations  it  is  evident,  that  whenever  disease  is 
attended  with  either  a  temporary  or  a  permanent  alteration  in  the  tissue 
of  an  internal  organ,  it  will  be  of  the  greatest  practical  importance  to 
ascertain  the  nature  and  extent  of  that  alteration,  and  the  progress  of 
practical  medicine  will  be  exactly  proportioned  to  the  accuracy  witli 
which  this  can  be  accompHshed.     Thus,  how  much  has  the  treatment  of 


38  CLINICAL   MEDICINE. 

pectoral  diseases  been  improved  by  the  application  of  auscultation  ana 
percussion^ — means  which  are  only  useful  by  enabling  us  to  ascertain 
the  physical  alterations  induced  by  the  disease,  or,  in  other  words,  the 
morbid  anatomy  of  the  affected  organ.  Without  their  aid,  how  trace 
the  progress  and  follow  the  increase  or  diminution  of  pulmonary  inflam- 
mation ? — how  demonstrate  the  existence  of  dropsical  or  pleuritic  effusion 
within  the  chest? — ^how  detect  latent  pneumonia? — ^how  distinguish 
with  certainty  pleurodyne  from  pleurisy  ?  I  could  prove  the  utter  im- 
possibility of  distinguishing  many  cases  of  broncliitic  from  tubercular 
phtliisis  without  their  assistance.  I  might  refer  to  chronic  emphysema 
of  the  pulmonary  tissue,  a  disease  of  great  importance,  but  actually  un- 
known before  the  time  of  Laeniiec,  who  fu-st  accurately  described  it  in 
the  dead  body ;  indeed,  before  the  application  of  percussion  and  auscul- 
tation, a  perfect  knowledge  of  this  derangement  of  the  pulmonary  struc- 
ture in  the  dead  body  would  not  have  assisted  our  diagnosis,  for  how 
recognise  it  during  life  ?  I  might  bring  forward  dilatation  of  the  bron- 
chial tubes,  another  disease  wholly  unknown  before  Laennec's  time,  and 
which,  before  his  discovery,  could  not  be  recognised  by  the  common 
method  of  observation.  I  might  enlarge  on  the  great  utility  of  attending 
to  the  changes  wliich  take  place  within  the  chest  in  measles  and  scarlet 
fever,  but  the  benefit  resulting  from  an  accurate  acquaintance  with  the 
morbid  anatomy  of  the  thoracic  cavity  is  now  so  generally  acknow- 
ledged, that  I  shall  rather  choose  my  illustrations  from  other  classes  of 
diseases. 

Nosologists,  until  very  lately,  were  agreed  in  attributing  considerable 
frequency  to  those  cases  of  apoplexy  and  paralysis,  which  arise  from 
serous  efl'usion  in  the  brain,  or  from  a  mere  functional  inaction  or  de- 
bility of  the  cerebral  and  nervous  systems.  This  opinion  was  founded 
partly  on  speculative  grounds,  and  partly  on  inadequate  and  imperfect 
post-mortem  examinations,  and  in  practical  books  the  symptoms  sup- 
posed to  announce  sanguineous,  serous,  and  nervous  apoplexy  were 
dogmatically  laid  down,  What  was  the  consequence? — Most  disastrous, 
as  I  have  had  occasion  to  witness  in  some  parts  of  the  continent,  where 
the  elderly  practitioners  stiU  adhered  to  the  practice  founded  on  this 
false  pathology.  What  can  be  more  melancholy  than  to  see  time  wasted 
or  misemployed  in  the  exhibition  of  diuretics,  given  to  promote  ab- 
sorption of  serum  effused  into  the  brain,  or  of  strong  exciting  remedies, 
such  as  arnica,  camphor,  &c.,  to  overcome  the  nervous  debihty,  in  cases 
where  copious  depletion  by  the  lancet  and  purgatives  were  urgently  ne- 
cessary. I  do  not  deny  that  in  some  rare  cases  serous  effusion  into  the 
brain  is  the  cause  of  death  from  apoplexy.  I  have  seen  such  an  event 
supervene  in  chronic  dropsy,  but  there  the  termination  was  very  sudden, 
and  the  previous  history  left  no  doubt  as  to  the  cause ;  but  in  the  ma- 


THE    STUDY    OF    MOKBIU    ANATOMY.  39 

jority  of  the  cases  formerly  treated  as  serous  or  nervous  apoplexy  a  more 
careful  examination  would  have  detected  marks  of  vascular  excitement, 
or  local  inflanunation,  a  subject  I  shall  treat  at  large  when  on  the  patho- 
logy of  the  brain.  A  similar  error  in  morbid  anatomy  led  to  a  similarly 
erroneous  practice  in  the  treatment  of  hydrocephalus,  and  many  cases  of 
general  and  local  dropsy.  The  effusion  occupied  the  sole  attention  of 
pathologists ;  the  marks  of  preceding  vascular  excitement  or  inflamma- 
tion escaped  their  notice. 

Time  will  not  permit  me  to  enlarge  upon  the  light  which  morbid  ana- 
tomy, rationally  pursued,  has  shed  upon  diseases  of  the  brain.  It  is 
sufficient  to  remark,  that  some  of  the  most  important  modifications  of 
inflammation  in  that  organ  have  been  only  lately  discovered,  and  it  is  only 
lately  that  a  minute  and  extensive  examination  of  the  different  changes 
the  brain  undergoes  in  disease,  has  begun  to  introduce  a  certain  degree 
of  regularity  and  precision  into  a  department  where  all  before  was  con- 
fusion and  inaccuracy. 

Examples  of  the  utility  of  morbid  anatomy  might  be  brought  forward 
without  number : — ^the  discovery  of  local  inflammation  being  at  times  the 
cause  of  a  disease  in  most  of  its  symptoms  resembling  common  ague ; 
the  use  of  the  lancet  in  the  cold  stage  of  ague,  a  practice  which  may  be 
advantageously  resorted  to,  in  cases  where  each  return  of  the  fit  is  accom- 
panied by  a  recurrence  of  inflammation  in  a  vital  organ,  as  the  lungs  or 
brain ;  the  connexion  between  inflammation  of  the  mucous  membrane  of 
the  stomach,  and  some  of  those  symptoms  of  fever  formerly  attributed  to 
mere  debility ;  the  influence  of  cerebral  inflammation  and  congestion,  in 
producing  the  symptoms  formerly  vaguely  denominated  typhus ;  the  low 
character  which  fever  assumes  when  accompanied  by  pneumonia  (and 
that,  too,  often  latent) ;  the  symptoms  which  are  produced  by  follicular 
ulceration  of  the  intestines,  which  so  frequently  occurs  in  the  course  of 
fever ;  the  diagnosis  between  the  pain  produced  by  neuralgia  of  the  ab- 
dominal nerves,  and  that  resulting  from  structural  diseases  of  the  intes- 
tinal canal;  a  more  accurate  knowledge  of  the  state  of  the  mucous 
membrane  in  the  diarrhoea  of  phtliisis,  and  in  intestinal  tympanitis ;  the 
numerous  improvements  in  the  treatment  of  diseases  of  the  ear,  which 
followed  Itard^s  investigations  concerning  the  morbid  anatomy  of  that 
organ; — these  and  many  other  discoveries,  all  replete  with  practical 
advantages,  are  the  results  of  the  attention  of  our  contemporaries  to 
morbid  anatomy.  And,  were  I  to  appeal  to  the  records  of  surgery,  I 
might  bring  forward  examples,  if  not  more  important,  perhaps  more 
evident  and  striking,  for  the  invention  and  success  of  most  capital  opera- 
tions depend  on  a  perfect  knowledge  of  the  structural  derangements, 
the  removal  or  cure  of  which  is  attempted.  Of  this,  examples  suggest 
themselves   on   every  side,    but  none  is  more  striking   than  the  one 


40i  CLINICAL   MEDICINE. 

devised  by  Bupuytren  for  the  cure  of  artificial  anus,  the  most  disgusting 
and  loathsome  malady  to  wliicli  human  nature  is  subject/  and  one  deemed 
altogether  incurable,  until  that  excellent  surgeon,  by  a  combination  of 
profound  pathological  and  physiological  knowledge,  succeeded  in  plan- 
ning and  executing  an  operation,  that  was  alone  sufficient  to  innnorta- 
lize  his  name. 

The  study  of  morbid  anatomy,  however,  is  attended  with  no  ordinary 
difficulties,  and,  when  imperfectly  understood,  is  liable  to  lead  to  erro- 
neous results,  for  it  requires  much  candour,  much  patience,  and  that 
experience  which  can  be  only  acquired  by  long  continued  practice,  to 
enable  us  to  judge  concerning  diseased  appearances.  The  power  of  ac- 
curately discriminating  in  the  dead  body  the  traces  of  disease  cannot  be 
suddenly  acquired,  and  so  numerous  are  the  various  errors  to  which  su- 
perficial observers  are  liable,  that  much  injury  has  thus  resulted  to  me- 
dical science,  diseased  appearances  being  in  some  cases  overlooked,  and 
in  others  recorded  where  they  did  not  exist.  Those  who  are  aware  how 
often  the  congestion,  which  frequently  takes  place  immediately  before  or 
after  death,  in  the  pulmonary  tissue,  and  in  the  mucous  membranes  of 
the  lungs  and  alimentary  canal,  alters  the  physical  properties  of  these 
parts,  so  as  almost  exactly  to  simulate  the  vestiges  of  inflammation,  will 
understand  how  it  happens  that  in  investigations  connected  with  the  real 
or  supposed  diseases  of  these  parts,  facts  have  been  marshalled  against 
facts,  and  observations  arranged  against  observations,  until  the  path 
which  promised  simplicity  and  order  terminated  in  perplexity  and  con- 
fusion. Hence  the  doctrines  of  Broussais  received  so  many  corrobora- 
tions, and  appeared  to  rest  upon  numerous  series  of  undoubted  and  well 
authenticated  facts. 

The  morbid  anatomist  must  of  all  tilings  beware  of  seeing  too  much. 
He  must  avoid  imposing  on  himself  by  everywhere  seeing  exactly  what 
he  expected  to  see,  and  above  all  things  let  him  not  always  force  himself 
to  see  something ;  for  many  diseases  proceed  to  a  fatal  termination  with- 
out having  produced  any  evident  morbid  alteration. 

Wlien  I  come  to  treat  of  the  pathology  of  the  brain  and  nervous  sys- 
tem, I  shall  have  occasion  to  advert  to  errors  which  late  authors  have 
committed  from  too  great  an  anxiety  on  the  one  hand  to  reduce  to  a 
certain  and  definite  system  the  morbid  appearances  of  the  brain  and 
spinal  marrow,  as  connected  wdth  their  diseases,  and,  on  the  other,  to 
find,  in  every  case  where  the  cerebral  or  nervous  functions  had  been 
diseased,  lesions  of  structure  to  account  for  the  symptoms.  Thus,  to 
cite  one  of  numerous  instances,  I  shall  have  occasion  to  prove  that  epi- 
lepsy and  mania  often  commence  suddenly  and  violently,  without  the 
existence  of  any  organic  alteration ;  and,  indeed,  that  organic  lesions  are 
not  necessarily  connected  with  these  formidable  diseases  is  sufficiently 


THE    STUDY    OF    MORBID    ANATOMY.  41 

proved  by  the  occasionally  sudden  manner  in  wliich  they  cease.  Thus, 
a  gentleman  of  great  literary  reputation  was  many  years  a  patient  of 
mine  before  his  death,  wliich  happened  in  1831,  at  the  age  of  seventy. 
Erom  the  age  of  twenty-five  to  fifty-five  he  suffered  from  violent  and  fre- 
quently recurring  fits  of  epilepsy;  after  having  continued  for  thirty 
years  the  disease  ceased  suddenly,  without  any  assignable  cause,  and 
during  the  last  fifteen  years  of  his  hfe  he  had  not  a  single  fit.  I  shall  have 
occasion  to  show  you  how  fine-drawn  and  how  ill-founded  are  the  obser- 
vations of  those,  who  profess  to  account  for  every  nervous  disturbance 
during  life  by  cerebral  lesions,  who  profess  to  distinguish  accurately 
during  life,  inflammation  and  irritation  of  the  araclmoid  or  dura  mater, 
from  irritation  or  inflammation  of  the  brain  itself,  who  maintain  that  one 
series  of  symptoms  is  produced  by  inflammation  of  the  cortical,  and 
another  by  inflammation  of  the  medullary  substance,  who  have  strained 
their  eyes  to  discover,  and  their  veracity  to  impose  upon  us,  proofs  that 
inflanunatory  or  other  diseased  states  of  certain  portions  of  the  brain  inva- 
riably caused  similar  afi^ections  of  certain  mental  functions.  These  errors 
of  some,  even  of  the  most  eminent  Trench  pathologists,  it  will  be  my 
duty  to  notice  from  time  to  time ;  but  I  am  sorry  to  say  that  much  more 
unpardonable  errors  and  misstatements  have  found  their  way  into  Eng- 
lish and  Irish  publications  on  the  pathology  of  the  brain,  and  which  I 
shall  be  compelled  to  speak  of  hereafter. 

Having  made  the  preceeding  observations  on  the  dangers  which 
arise  from  an  ill- directed  application  of  the  studies  of  physiology  and 
morbid  anatomy  to  the  practice  of  medicine  and  surgery,  I  feel  myself 
imperatively  called  on  to  present  the  other  side  of  the  question  to  your 
view,  in  exposing  the  still  more  dangerous  doctrine  advocated  by  those 
who  depreciate  the  value  of  pathology  and  morbid  anatomy  as  only 
instructive  after  the  death  of  the  patient — and  even  then  as  not  un- 
frequently  calculated  rather  to  mislead  than  to  advance  the  interests  of 
practical  medicine.^ 

It  must  be  conceded  that  he  who  is  only  a  physiologist  cannot  hope 
to  cure  disease,  and  that  the  mere  morbid  anatomist  will  be  often 
misled  by  post  mortem  appearances — if  he  have  not  attentively 
watched  the  progress  of  symptoms  and  the  effects  of  medicines  during 
life;  for,  unless  this  be  done,  he  will  as  I  have  already  said,  often 
mistake  secondary  for  primary  lesions,  will  confound  effects  with  their 
causes,  and  mU  refer  to  certain  alterations  of  structure  that  which  had 
originated  in  a  functional  disorder :  a  morbid  state  of  parts  very  dif- 
ferent from   that   wliich   is  observed  after  death.      But  when,  to  an 

*  The  dangers  above  enumerated  may  be  almost  all  avoided  by  institutions,  such  as  the 
Dublin  Pathological  Society,  founded  in  1838,  and  by  means  of  which  morbid  specimens 
are  exposed  to  an  examination  most  likely  to  disclose  their  real  nature. 


4^  CLINICAL   MEDICINE 

accurate  knowledge  of  physiology  and  morbid  anatomy  is  joined  an 
extensive  observation  of  the  progress  of  symptoms  and  the  effects 
of  therapeutical  agents,  how  much  more  certain  and  satisfactory  will  be 
our  practical  decisions,  and  how  much  more  likely  our  efforts  to  be 
attended  mth  success,  than  if  we  merely  studied  disease  at  the  bed- 
side of  the  patient.  In  the  latter  case  we  might  indeed  become  expert 
nosologists,  be  accurately  acquainted  with  certain  groups  of  symptoms, 
and  even  not  unfrequently  adopt  the  proper  method  of  treatment. 
These  symptoms,  considered  together,  we  would  call  by  a  certain  name, 
and  hand  down  to  posterity  this  new  acquisition  of  medical  knowledge, 
perhaps  clothed  in  the  garb  of  a  dead  language,  and  invested  with  the 
false  dignity  of  a  learned  tongue.  But  what  have  we  really  thus 
effected  for  posterity  ? — Our  followers  read  our  definitions  of  disease 
with  an  acquiescing  admiration,  and,  sure  of  the  efficacy  of  the  re- 
medies we  have  recommended,  they  go  forth  with  an  over-weening 
confidence  in  quest  of  the  group  of  symptoms  we  have  described, 
and  when  they  have  met  with  them  they  look  upon  their  task  as 
already  liaK  accomplished,  and  promise  a  successful  termination  of  the 
disease. 

"  Tell  me  the  name  of  the  disease,^'  was  the  motto  of  the  nosologist, 
"  and  I  will  tell  you  the  remedy  f  but,  gentlemen,  I  will  engage  to 
teU  you  the  names  of  a  hundred  diseases,  without  your  being  able  to 
name  the  proper  method  of  treatment,  I  tell  you  a  man  has  dropsy, 
his  Hmbs  are  anasarcous,  water  is  accumulated  in  the  peritoneal  cavity, 
his  urine  is  scanty,  and  his  thirst  increased.  Will  you,  from  this  very 
excellent  nosological  definition  venture  to  prescribe  for  this  case  of 
dropsy?  Tor  the  sake  of  the  suffering  patient  and  your  own  con- 
science, prescribe  not  on  such  data.  And  yet  I  regret  to  be  obliged  to 
say,  that  such  a  method  of  proceeding  is  by  no  means  rare,  nay,  it  is 
even  a  matter  of  daily  occurrence.  But  this  case  of  dropsy  will  not 
yield.  Some  other  boasted  specific  hydragogue  or  diuretic  is  had 
recourse  to ;  still  the  patient  grows  worse  and  worse,  and  finally  dies, 
but  his  friends  are  not  discontented  with  the  medical  attendant,  who 
excuses  himself  by  asserting  that  he  has  successively  resorted  to  every 
remedy  which  has  been  recommended  in  dropsy ;  and  in  truth  if  you 
look  over  the  list  of  medicines  exhibited  in  rapid  succession,  you  wiH 
probably  find  that  his  excuse  is  not  unsupported  by  facts.  But,  gentle- 
men, these  cases  in  wliich  every  tiling  has  been  tried,  are  exactly  those 
in  wliich  nothing  has  been  tried,  in  which  medicine  has  followed  medi- 
cine, and  each  symptom  of  disease  has  indiscriminately  been  the  object 
of  attack,  until  death  approaches  with  accelerated  steps,  and  charitably 
closes  a  scene  distressing  to  humanity,  and  disgraceful  to  the  cause — I 
was  going  to  say — of  science,  but  who  will  venture  to  give  so  emiobhng 


GENERAL    REMARKS.  43 

a  name  to  this  pseudo-practical  knowledge,  this  worse  than  absolute 
ignorance  ? 

Gentlemen,  I  am  not  combating  phantoms  ;  I  do  not,  Quixote-like, 
contend  with  imaginary  giants ;  no,  gentlemen,  what  I  have  described 
exists,  the  picture  I  have  drawn,  has  many  an  original.  But  let  us 
have  done  with  this  subject ;  let  us  turn  to  the  gratifying  considerations 
of  the  progress  which  practical  medicine  is  making  under  its  parent 
sciences, — physiology  and  morbid  anatomy. 

The  reason  of  man  is  now  more  fully  employed  than  at  any  former 
period,  a  vast  store  of  mental  power,  a  vast  mass  of  mind  is  everywhere 
at  work ;  what  formerly  was  vainly  attempted  by  the  labour  of  a  few,  is 
now  easily  accomplished  by  the  exertions  of  the  many.  The  empire 
of  reason,  extending  from  the  old  to  the  new  world,  from  Europe  to 
our  Antipodes,  has  encircled  the  earth  :  the  sun  never  sets  upon  her 
dominions, — individuals  must  rest,  but  the  collective  intelligence  of 
the  species  never  sleeps ;  at  the  moment  one  nation,  wearied  by  the 
toils  of  day,  welcomes  the  shades  of  night,  and  lies  down  to  seek 
repose,  another  arises  to  hail  the  light  of  morning,  and,  refreshed,  speeds 
the  noble  work  of  science  ! 

AR  inquirers  commence,  as  it  were,  at  the  same  point,  as  the  labours 
of  their  predecessors  are  equally  at  the  disposal  of  all,  and  conse- 
quently it  is  not  surprising  we  should  often  find  them  arriving  together 
at  the  same  end ;  thence  the  number  of  simultaneous  discoveries  of  the 
same  fact  now  so  common.  It  is  not  unusual  to  find  the  publications 
of  Prance,  Germany,  Italy,  and  England,  announcing  the  same  dis- 
covery, and  each  zealously  claiming  for  their  respective  countrymen  an 
honour  which  belongs  equally  to  all.  I  am  sorry  to  say  that,  with 
some  splendid  exceptions,  this  interesting  and  innocent  controversy 
had  been  carried  on  by  other  countries,  while  Ireland  had  put  in  no 
claim  for  a  share  of  the  literary  honours  awarded  to  the  efforts  of 
industry  or  genius.  But,  gentlemen,  this  state  of  inaction,  this  state 
of  mental  torpor,  is  daily  ceasing,  and  the  time  has  passed  away  when 
we  could  not  point  out  among  our  bretliren  any  who  had  advanced  the 
boundaries  of  the  medical  sciences^  and  thus  promoted  the  interests  of 
humanity. 

Now  we  can  enumerate  many  w^hose  names  form  a  catalogue  the 
subject  of  congratulation  for  the  present,  of  happy  augury  for  the 
future, — for  cold  must  be  the  breast  of  him  who  will  not  hail  with 
joy  every  symptom  of  our  country's  hterary  regeneration, — dead  the 
feelings  which  are  not  elated  at  the  boon  conferred  on  our  species  by 
every  advance  made  by  those  who  devote  themselves  to  the  grand,  the 
noble,  pursuit  of  relieving  the  suffering,  of  healing  the  diseased.  But 
time  bids  me  stop,  I  shall,  therefore,  conclude  by  observing  that  the 


%%  CLINICAL   MEDICINE. 

attention  lately  devoted  to  the  distinctions  between  real  and  pseudo- 
morbid  appearances,  the  diligent  cultivation  of  morbid  anatomy  by  men 
not  the  slaves  of  preconceived  opinions,  the  abandonment  of  all  systems 
whose  baseless  fabric  rests  on  the  phantoms  of  vital  physiology,  the 
importance  now  justly  attached  to  medical  statistics,  to  the  study  of 
endemic  and  epidemic  maladies,  to  the  operation  of  morbid  poisons : 
these,  and  various  other  circumstances,  give  us  reason  to  hope  that  the 
progress  of  the  human  mind  in  investigating  the  means  of  preventing 
and  curing  diseases,  will  not  be  less  rapid  than  it  has  been  in  the  other 
departments  of  knowledge.  And  thus  it  will  be  proved  that  if  man 
has  passions  which  impel  him  to  the  destruction  of  man,  if  he  be  the 
only  animal  who  despising  his  natural  weapons  for  attack  or  defence, 
has  devised  new  means  of  destruction, — he  is  also  the  only  animal  who 
has  the  desire  or  the  power  to  reheve  the  sufferings  of  his  fellow- 
creatures;  the  only  animal  in  whom  the  co-existence  of  reason  and 
benevolence  attests  a  moral  as  well  as  an  intellectual  superiority. 


45 


LECTURE  IV. 

THE    PULSE. 

The  posture  of  the  body  has  a  very  considerable  influence  on  the 
frequency  of  the  pulse,  even  in  healthy  persons,  and  this  influence  being 
still  more  marked  in  disease,  it  has  been  long  a  matter  of  common 
observation,  that  the  pulse  is  more  frequent  in  the  erect  than  in  the 
horizontal  posture.  Tliis  subject,  not  having  been  investigated  with 
the  accuracy  it  merits,  I  have  made  it  the  object  of  numerous  experi- 
ments, the  results  of  which  appear  in  some  respects  novel,  and  not 
devoid  of  practical  utility.  In  healthy  persons  the  pulse  in  the  erect 
posture  is  more  frequent  than  in  the  horizontal,  by  from  six  to  fifteen 
beats  in  the  minute.  If  the  pulse  is  but  sixty  the  difference  is  gener- 
ally not  more  than  six  or  eight,  and  this  difference  increases  with  the 
frequency  of  the  pulse  at  the  time  of  the  experiment :  thus  if  it  has 
been  raised  to  90  or  100  by  moderate  exercise,  it  is  not  unusual  to  find 
the  difference  twenty  or  thirty. 

As  the  muscular  exertion  necessary  to  keep  the  body  in  the  erect 
posture,  might  be  considered  as  the  cause  of  tliis  greater  frequency,  it 
became  necessary  to  contrive  means  of  placing  the  body  in  any  de- 
sired posture,  without  the  necessity  of  muscular  exertion  on  the  part  of 
the  subject  of  the  experiment ;  this  was  effected,  and  it  was  found  that 
when  the  posture  was  changed  by  means  of  such  a  contrivance,  the  dif- 
ference between  the  frequency  in  the  horizontal  and  the  erect  postures, 
was  not  less  than  when  muscular  exertion  was  used. 

I  now  anticipated,  that  if  the  body  was  placed  with  the  head  down 
and  the  feet  up,  a  stiU  further  retardation  of  the  pulse  would  be  pro- 
duced ;  it  was,  indeed,  natural  to  conclude  from  the  preceding  experi- 
ments, that  posture  alone  was  the  cause  of  the  retardation  observed  in 
the  body  when  placed  horizontally,  and  consequently,  that  this  effect 
would  be  augmented  on  still  more  depressing  the  head,  and  that  the 
maximum  of  retardation  would  occur  in  the  inverted  position. 

I  was  incHned  still  more  to  this  opinion  from  considering,  that  in  the 
inverted  position,  the  return  of  blood  from  the  brain,  being  opposed  by 
the  force  of  gravity,  that  organ  would  necessarily  become  the  seat  of 
sanguineous  congestion,  to   a   degree   capable  of  producing   cerebral 


46  CLINICAL   MEDICINE. 

compression  and  consequent  retardation  of  the  pulse ;  for  I  cannot  sub- 
scribe to  tbe  opinion  of  Dr.  Abercrombie  and  others  who  maintain,  that 
the  quantity  of  blood  circulating  within  the  cranium  never  varies  in 
quantity^ ;  here,  however,  as  it  not  unfrequently  happens,  preconceived 
ideas  were  not  found  to  accord  wdth  experiment,  and  no  further  retar- 
dation of  the  pulse  w^as  thus  affected,  neither,  on  the  other  hand,  was 
it  accelerated  beyond  the  number  observed  in  the  horizontal  position. 
This  fact  I  verified  by  experiments  made  in  the  presence  of  Dr.  Jacob, 
Dr.  Apjohn,  and  Mr.  Harris.  It  appears  very  singular,  that  a  posture 
so  unnatural  as  the  inverted,  should  produce  no  effect  on  the  frequency 
of  the  pulse,  as  compared  with  the  horizontal,  wliile  a  change  from  the 
latter  to  the  erect,  both  natural  postures,  is  attended  with  so  great  an 
acceleration.  In  the  inverted  posture,  although  the  frequency  of  the 
pulse  is  not  altered,  its  strength  is  diminished,  and  often  very  consider- 
ably ;  it  is  not  unusual  too,  for  it  to  become  irregular,  a  fact  that  may 
be  explained  by  the  greater  weight  of  the  blood  pressing  back  on  the 
aortic  valves,  and  thus,  necessarily  opposing  an  unusual  impediment  to 
its  egress  from  the  left  ventricle.  The  pulse  is  also  evidently  stronger 
in  the  horizontal  than  in  the  erect  posture,  consequently  its  maximum 
of  strength,  and  minimum  of  frequency,  are  attained  together.  This, 
may,  I  conceive,  account  more  satisfactorily  than  has  been  hitherto 
done,  for  the  relief  obtained,  by  placing  patients  in  the  horizontal 
posture,  in  order  to  avoid  syncope,  as,  for  instance  that  produced  by 
venesection.  In  all  other  diseases  t  in  which  I  have  investigated  this 
subject,  I  have  found  a  difference  between  the  frequency  of  the  pulse 
in  the  erect,  sitting,  and  horizontal  postures ;  hut  in  six  cases  of  hy- 
pertropJiy  with  dilatation  of  the  heart,  no  such  difference  was  per- 
ceptihle,  although  all  these  patients,  at  the  tirne  of  my  making  the 
experiment,  were  in  a  debilitated  state,  which,  it  will  just  now  appear 
is  that  in  which  the  changes  induced  by  position  are  the  most  remark- 
able. In  four  of  these  cases  the  existence  of  hypertrophy  with 
dilatation  has  been  ascertained  by  post  mortem  examination,  and  of 
the  other  two,  a  man,  and  a  woman,  at  present  in  the  Meath  Hospital, 

*  Dr.  Burrowes  of  London  has  recently  tested  by  experiment  the  truth  of  Abercrorabie's 
assertion,  and  he  has  satisfactorily  proved  that  the  quantity  of  the  blood  circulating 
within  the  brain  does  vary  under  different  circumstances,  and  is  especially  influenced  by 
the  position  of  the  body.  I  must  refer  to  his  excellent  book  on  the  "  Cerebral  Circula- 
tion," published  in  184fi,  for  an  account  of  the  experiments  he  performed,  and  their 
results. 

+  Owing  to  the  kindness  of  Mr.  Sohan,  I  had  an  opportunity  of  examining  the  pulse 
of  a  lady,  aged  50,  of  strong  constitution,  in  whom  since  her  childhood,  the  frequency  of 
the  pulse  has  never  exceeded  38  in  a  minute.  It  is  the  same  in  all  postures,  and  its 
frequency  is  not  altered  by  the  accession  of  febrile  or  inflammatory  affections.  There  is 
no  suspicion  of  any  disease  of  the  heart. 


THE    PULSE.  47 

tliere  can  be  no  doubt  of  the  state  of  the  heart  in  one  of  them,  wliile 
in  the  other,  the  existence  of  hypertrophy  is  more  than  probable.  For 
the  sake  of  accuracy  I  shall  give  the  precise  results  of  the  experiments 
I  made  before  you  on  these  six  patients ;  where  two  numbers  follow 
each  other,  they  denote  successive  quarters  of  a  minute,  that  being 
first  which  immediately  followed  the  change  of  posture. 

Doyle,  Monday^  Pulse  in  Horizontal  Position,        72 

Sitting,        72 

-< Standing,     80 

Tuesday^  Horizontal, 72 

Sitting,        80,72 

Standing,     80,  72 

Wednesday^ H  orizon  tal, 72 

Sitting,        72 

Standing,     72 

Malone,  Pulse  in  Horizontal  Position,        60 

Sitting 7f>,  fiO 

Standing,     76,  60 

In  both  of  these  cases,  althougli  the  pulse  during  the  first  quarter  of 
a  minute  after  the  change  of  posture,  rose  in  frequency,  yet  in  the  next 
it  fell  to  the  previous  standard ;  indeed  it  may  be  remarked  that  the 
greatest  frequency,  where  muscular  exertion  has  been  used  to  assume  the 
sitting  or  erect  posture,  is  observable  in  the  first  ten  seconds  wliich 
follow  that  exertion,  both  in  health,  and  still  more  remarkably  in 
disease ;  and  consequently  the  first  quarter,  or  even  half  of  a  minute^ 
should  be  rejected  where  we  msh  to  ascertain  the  permanent  alteration 
thus  produced. 

In  two  other  cases,  Gorman  and  Reilly,  in  whom  the  hypertrophy 
and  dilatation  had  attained  to  a  great  size,  even  this  acceleration  during 
the  first  few  seconds  was  scarcely  perceptible,  and  the  pulse  almost  at 
once  resumed  its  former  standard.  The  same  observation  appKes  to 
the  two  patients  at  present  (5th  July,)  in  the  hospital ;  in  the  man 
the  pulse  is  76,  both  when  he  is  lying  or  sitting;  in  the  woman,  in 
whom  certainly  extreme  hypertrophy  with  dilatation  exists,  the  pulse  is 
constantly  above  100,  and  the  same  in  both  postures.  They  have  been 
both  long  ill,  and  are  much  debilitated  by  the  efi'ects  of  the  disease,  and 
of  the  remedies  employed  to  mitigate  its  violence. 

In  these  cases  of  diseased  heart  I  have  already  remarked,  the  hyper- 
trophy and  dilatation  were  very  great,  and  in  five  of  them  certainly, 
and  in  the  sixth  probably,  the  left  ventricle  was  involved  in  the 
disease;  and  I  am  incHned  to  tliink,  that  this  permanence  of  the 
pulse  in  aU  positions  of  the  body,  wiU  be  only  found  to  exist  in 
such  cases,  and  not  in .  those  where  the  hypertrophy  and  dilatation 
are  less   considerable,   and  consequently  the  diagnosis  more  obscure. 


48  CLINICAL   MEDICINE. 

This  circumstance  may,  it  is  true_,  detract  from  the  value  of  the 
observation  so  far  as  regards  diagnosis^  but  certainly  does  not  diminish 
its  physiological  interest :  I  may  observe,  too,  that  should  future 
observations  prove  that  hypertrophy  of  the  heart  is  not  always  attended 
by  this  permanency  of  the  pulse,  and  I  believe  it  is  not,  yet  its  occur- 
rence in  so  many  cases  of  that  affection  is  nevertheless  an  interesting 
fact.  In  pursuing  this  inquiry  it  -will  be  necessary  to  compare  the 
effects  of  posture  in  hypertrophy  with,  and  without,  disease  of  the  valves 
of  the  heart  and  aorta.  It  would  be  premature  to  inquire  into  the 
cause  of  this  phenomenon,  but  it  immediately  suggests  itself  to  the 
mind,  that  it  depends  on  the  increased  strength  and  energy  of  the  left 
ventricle  when  in  a  state  of  hypertrophy,  and  which,  in  a  great 
measure,  place  its  contractions,  as  it  were,  beyond  the  influence  of 
these  causes  wMch,  in  other  diseases,  attended  with  debility,  and  even 
in  many  persons  in  health,  enable  a  change  of  posture  to  produce  so 
remarkable  an  alteration  in  the  frequency  of  the  pulse.  I  shall  now 
give  the  results  of  a  great  number  of  observations,  made  both  in 
hospital  and  in  private  practice,  upon  this  effect  of  change  of  posture 
on  the  frequency  of  pulse  in  other  diseases. 

1st.  That  the  greatest  difference  occurs  in  patients  labouring  under 
fever,  or  in  a  debilitated  state  in  consequence  of  fever  or  any  other 
cause.  It  may  amount  to  30,  40,  or  even  50,  between  the  horizontal 
and  erect  postures. 

2dly.  That  this  difference  decreases  after  the  first  quarter  of  an 
hour  in  most  cases,  but  always  remains  considerable,  as  long  as  the 
same  position  is  observed. 

3dly.  That  in  persons  not  much  debilitated  the  difference  is  much 
less  than  that  stated  above,  and  often  does  not  amount  to  more  than 
10. 

4thly.  That  when  the  patient  lies  down,  the  pulse  rapidly  falls  to 
its  former  standard. 

Stilly.  That  in  some  the  increase  in  frequency  is  greater  between  the 
horizontal  and  sitting  posture,  than  between  the  latter  and  the  erect ; 
while  in  others  the  contrary  takes  place,  so  that  generally  the  frequency 
in  the  sitting  posture  may  be  taken  as  a  mean. 

Gtlily.  In  persons  convalescent  from  fever  or  acute  diseases,  I  find  it 
is  extremely  useful  to  the  physician  to  ascertain  the  comparative  fre- 
quency of  the  pulse  in  the  horizontal  and  in  the  erect  position.  The 
greater  the  difference,  the  greater  is  the  debiHty  of  the  patient,  and 
consequently  the  more  guarded  must  his  medical  attendant  he  in  allotv- 
ing  hifn  to  sit  up  for  any  length  of  time,  particularly  if  the  pulse  on 
his  lying  domi  does  not  resume  its  usual  degi'ee  of  frequency.  ^ 


THE    PULSE.  49 

In  the  case  of  a  young  man  named  St.  Leger,  who  was  lately  a  patient 
at  Sir  Patrick  Dun^s  Hospital,  the  variation  of  the  pulse  in  different 
positions  of  the  body  was  very  remarkable.  He  was  just  recovering 
from  fever,  and  exhibited  a  state  of  the  pulse  w^liich  is  not  unfrequently 
observed  under  similar  circumstances.  During  his  convalescence  the 
pulse  went  on  declining  in  frequency,  until  it  sank  to  thirty-six  in  the 
minute.  When  I  made  him  sit  up  in  bed,  his  pulse  began  to  rise 
rapidly,  and,  in  the  space  of  a  minute,  was  at  sixty-four.  When  he 
stood  up  it  became  much  quicker,  hut  greio  so  weak  and  indistinct,  that 
it  could  not  he  felt  at  the  wrist.  On  applying  a  stethoscope  over  the 
region  of  the  heart,  I  found  that  its  pulsations  amounted  to  112  in  the 
minute.  Here  is  a  very  remarkable  difference  of  pulse  depending 
entirely  on  change  of  position.  With  respect  to  the  immber  of  respi- 
rations in  this  young  man,  I  found  that  when  lying  down  they  were 
only  fourteen,  but  when  he  stood  up  they  were  thirty.  This  is  a  very 
curious  fact,  and  one  which  I  have  not  before  observed. 

In  this  case,  the  pulse  was  very  little  more  than  in  the  proportion  of 
two  and  a  liaK  to  one,  as  compared  with  respiration,  whereas  it  ought 
to  be  as  four  to  one.  We  had  another  case  at  the  same  time  in  the 
Hospital,  in  which  the  pulse  was  84,  and  the  respiration  42  in  a 
minute;  and  a  third  case,  in  which  the  pulse  was  120,  while  the  res- 
piration was  only  twelve.  I  have  myself  seen  one  case  in  which  the 
pulse  was  60,  and  the  respiration  50. 

This  variation  in  the  relations  which  the  pulse  and  respiration  bear 
to  each  other,  is  principally  observed  in  fever  and  pulmonary  disease. 
I  am  at  present  attending  a  lady  in  fever,  whose  pulse  was  120,  and 
respiration  26,  until  within  the  last  twenty-four  hours,  since  which 
respiration  has  increased  to  40,  but  the  pulse  has  sunk  to  86.  Now, 
is  this  lady's  state  improved  ?  Would  you  prefer  having  her  in  her 
present  or  past  condition  ?  Eor  my  part,  I  will  say  that  in  such  a 
case  I  would  rather  have  the  pulse  than  the  respiration  accelerated.  A 
quickening  of  the  breathing  in  fever,  without  any  particular  lesion  of 
the  thoracic  viscera,  is  always  a  proof  that  the  muscular  powers  of 
organic  life  have  been  injured;  that  the  diaphragm  and  respiratory 
muscles  are  impeded  in  their  functions ;  and  that  the  case  is  of  a  dan- 
gerous character. 

I  do  not  know,  gentlemen,  any  point  on  which  accurate  observations 
are  more  wanting  than  on  the  proportion  between  the  pulse  and 
respiration  in  various  states  of  the  system,  and  in  various  diseases. 
Tacts  upon  this  subject  might  be  easily  collected,  and  would  probably 
lead  to  curious  and  instructive  results.  This  would  form  an  excellent 
subject  for  a  monograph,  and  might  be  investigated  by  any  student 

VOL.    I.  4 


50  CLINICAL  MEDICINE. 

who  possesses  attention  and  perseverance,  and  has  extensive  opportu- 
nities for  observation.  Having  touched  upon  the  change  in  the 
frequency  of  the  pulse  produced  by  alteration  of  position,  I  may  here 
remark  that  subsequent  observations  have  confirmed  the  vahdity  of  the 
diagnostic  mark  which  I  was  the  first  to  draw  from  this  circumstance  in 
distinguishing  functional  from  organic  disease  of  the  heart.  The 
general  proposition  may  now  be  considered  as  established,  that  in  a 
debilitated  person,  when  a  sudden  change  of  position  makes  little  or 
no  difference  in  the  frequency  of  the  pulse,  we  may  conclude  that  the 
heart,  or  at  least  its  left  ventricle,  is  increased  in  size  and  strength. 

A  dicrotous  pulse  is  a  prognostic  sign  of  great  value  in  many 
diseases.  The  following  conclusions  of  much  practical  importance  are, 
I  think,  especially  deserving  your  careful  attention : — 

In  fever,  a  dicrotous  pulse,  which  is  at  the  same  time  hard,  is  a  very 
had  symptom,  if  it  last  more  than  24  hours  :  when  succeeded  by  epis- 
taxis,  and  when  it  disappears  after  moderate  epistaxis  it  is  not  bad ;  it 
may  in  the  same  fever  thus  appear  and  disappear  several  times,  but 
each  time  it  becomes  more  serious.  When  in  fever,  a  hard  dicrotous 
pulse  lasts  for  many  days  without  any  tendency  to  hemorrhage,  the 
case,  in  nine  out  of  ten,  ends  fatally. 

In  hemoptysis,  epistaxis  and  internal  inflammations,  a  very  hard 
dicrotous  pulse  sometimes  occurs,  which  resists  all  treatment,  and 
portends  a  fatal  issue;  no  matter  how  much  the  other  symptoms 
may  improve,  so  long  as  the  pulse  continues  of  this  character,  the 
patient   is  in  imminent  danger. 

To  return  however  to  what  I  was  before  speaking  of — the  effects 
of  posture  on  the  pulse  : — Authors  who  have  written  concerning  the 
effects  of  digitalis  on  the  organs  of  circulation,  speak  of  the  difference 
between  the  pulse,  as  observed  in  different  positions,  as  an  inex- 
plicable anomaly,  and  seem  quite  ignorant  that  a  similar  phenomenon 
occurs  in  a  less  degree  in  health,  and  in  an  equal  degree  in  many 
diseases.  The  fact  appears  to  be,  that  digitalis y  besides  a  great  and 
debilitating  influence  on  the  whole  constitution,  and  particularly  the 
nervous  system,  possesses  a  peculiar  power  of  diminisliing  the  fre- 
quency of  the  pulse ;  hut  it  is  no  anomaly  that,  in  persons  under  its 
influence,  debilitated,  and  nervous  as  they  always  are,  when  it  is  ex- 
hibited in  doses  sufficient  to  retard  the  pulse,  there  should  be  a  great 
difference  between  the  frequency  of  the  pulse  as  examined  in  the 
horizontal,  the  sitting,  and  the  erect  postures. 

I  need  scarcely  add,  that  I  cannot  advance  even  a  plausible  conjec- 
ture, concerning  the  reason  why  a  change  of  position  should  so  affect 
the  frequency   of  the  pulse.     It  is  singular   enough,  however,   that 


THE   PULSE.  51 

Humboldt  should  have  observed  something  similar  in  the  hearts  of 
frogs,  cut  out  of  the  body,  the  great  vessels  being  tied.  In  one  of 
these  experiments  the  heart  being  placed  on  a  piece  of  glass  horizon- 
tally, after  12  minutes  its  pulsations  had  sunk  to  12  in  a  minute.  It 
was  now  suspended  perpendicularly,  and  after  2  minutes  the  number  of 
pulsations  rose  to  20."^"  Baerj  in  liis  work,  Tiber  Entwickelung  ge- 
schichte  der  Thiere,  &c.  has  made  the  curious  observation,  that  in 
hatching  eggs  artificially,  the  chick  in  ovo  soon  dies  if  the  egg  be  so 
placed  as  to  rest  on  either  end.  This  circumstance,  wliich  he  does  not 
attempt  to  explain,  suggests  an  obvious  and  beautiful  explanation  of 
the  reason  why  eggs  are  not  round  but  oval,  as  the  latter  shape  effect- 
ually prevents  them  from  assuming  a  position  in  the  nest  which  would 
be  fatal  to  the  enclosed  foetus.  Some  ova,  as  for  instance  those  of 
certain  reptiles,  are  round ;  but  I  know  of  no  bird  whose  eggs  are  not 
more  or  less  oval.  It  would  be  interesting  to  investigate  the  cause  of 
this  phenomenon,  as  also  to  examine  into  the  reasons  of  the  remarkable 
difference  which  exists  between  the  effects  of  position  on  the  human 
foetus  in  utero,  and  on  the  human  adult.  In  the  former  the  inverted 
or  semi-inverted  position  of  the  body  is  the  natural  position ;  in  the 
latter  it  is  insupportable  for  any  length  of  time. 

*  Annals  of  Medicine.,  vol.  iv.  239. 


53 


LECTURE  V. 

THE    GENERAL   LAWS    OP    INFLAMMATION. MARSHALL    HALLOS    VIEW3. 

THE  CIRCULATION  OF  THE  BLOOD. INFLUENCE  OF  THE  CAPILLARIES. 

Gentlemen — The  general  laws  which  govern  inflammatory  action,  and 
the  relation  which  the  vascular  system  bears  to  that  process,  constitute 
a  most  importalit  subject,  which  has  engaged  the  attention  of  the  ablest 
pathologists  and  practitioners  in  this  country  for  the  last  half  century. 
Since-  the  date  of  the  great  John  Hunter's  celebrated  work,  which  gave 
the  first  impulse  to  this  investigation,  many  British  and  Continental 
writers  have  applied  their  talents  to  the  illustration  of  the  changes 
the  vascular  system  undergoes  during  the  progress  of  inflammation. 
Thomson,  Hastings,  "W.  Philip,  James,  Burns,  and  Marshall  Hall, 
have  performed  numerous  and  interesting  experiments,  which  throw 
light  on  its  phenomena ;  and  we  have  gained  much  by  the  assiduity  and 
research  they  have  displayed,  in  endeavouring  to  illustrate  a  matter  of 
such  acknowledged  difficulty.  Still,  these  authors  appear  to  have 
adopted  some  erroneous  views,  and  to  have  misunderstood  or  over- 
looked some  points  of  peculiar  importance.  I  shall  first  direct  your 
attention  to  the  opinions  of  Dr.  Marshall  Hall  as  explained  in  his 
lectures,  pubhshed  in  the  Lancet,  Dr.  Hall,  possessing  extensive 
acquirements  and  high  professional  reputation,  has  cultivated  the 
sciences  of  physiology  and  pathology  with  distinguished  zeal,  and 
made  numerous  experiments  and  microscopical  observations,  tending  to 
illustrate  the  subject  of  inflammation;  his  opinions  are,  therefore, 
entitled  to  serious  consideration. 

Speaking  of  the  inflammatory  process.  Dr.  Hall  observes — "  I  con- 
clude that  each  cause  of  inflammation  first  induces  such  a  physical 
efibct  upon  the  internal  surface  of  the  capillaries,  as  leads  to  the  ad- 
herence of  the  globules  of  blood  to  it,  and  to  their  ultimate  stagnation. 
This  stagnation  augments  as  the  inflammation  increases,  and  becomes 
more  diffused,  and  seems  to  constitute  the  essential  character  of  the 
disease.^'  Here  you  perceive  that  he  believes  the  first  step  to  be  the 
adherence  of  the  globules  of  the  blood  to  the  internal  surface  of  the 


INFLAMMATION.  53 

capillaries ;  the  consequence  of  which  is,  that  the  calibre  of  these 
vessels  is  considerably  diminished,  so  that  they  become  obstructed,  and 
cause  a  stagnation  of  the  blood,  which  Dr.  Hall  looks  upon  as  the 
essential  character  of  inflammation. 

Further  on  he  says — "  I  have  never  been  able  to  detect  any  action  in 
the  capillaries  themselves.  It  is,  probably,  by  the  partial  obstruction  to 
the  circulation  in  the  capillaries,  that  the  minute  arteries  become  en- 
larged.^' Now  observe,  according  to  this  mode  of  explanation,  the  cir- 
culation being  obstructed  in  the  capillaries,  in  consequence  of  the 
adherence  of  the  globules  of  blood  to  their  sides,  the  arteries  which 
supply  them  are  propelling  blood  into  obstructed  vessels,  and  conse- 
quently become  enlarged  or  dilated— and  why  ?  Dr.  Hall  says,  "  ac- 
cording to  the  well-known  law,  that  muscular  organs  augment,  with 
obstacles  to  their  functions."  Here  I  may,  in  the  first  place,  observe, 
that  Dr.  Hall  is  not  warranted  in  looking  upon  the  minute  arteries  as 
muscular  organs ;  but  waiving  tliis  point,  how  can  the  law  alluded  to 
explain  the  supposed  increase  in  the  capacity  of  the  minute  arteries  ? 
It  might,  indeed,  explain  the  increase  of  thickness  in  their  parietes ; 
but  is  it  not  plain,  that  this  very  addition  to  the  tliickness  of  the  arterial 
walls,  so  far  from  increasing,  must  diminish  their  calibre  ? 

Again,  he  observes — "  It  is  probably  by  the  fact  of  stagnation  that 
inflammation  differs  from  blushing,  eruptions,  &c."  Here,  you  perceive, 
he  introduces  the  qualifying  term,  "  probably."  He  continues — "  It  is 
generally  asserted,  that  there  is  a  series  of  vessels  which  only  circulate 
the  serum  of  the  blood,  and  exclude  the  globules.  This  I  believe  to  be 
mere  hypothesis.  Vessels  which  only  admit  of  single  globules  will  ap- 
pear colourless.  In  inflammation,  the  minute  arteries  wliich  only  admit 
single  globules  at  a  time,  enlarge,  and  admit  a  greater  number,  and  then 
the  red  colour  becomes  visible."  He  goes  on  then  to  say — ^'  This  en- 
largement of  the  blood-vessels  is  not  confined  to  the  minute  arteries,  for 
the  larger  vessels  in  the  immediate  vicinity  of  the  inflamed  part  also  be- 
come enlarged.  -J?-  ^  ^  ^  This  is  owing  to  the  obstruction  of  the 
true  capillaries."  And  he  illustrates  this  by  instancing  the  application 
of  a  ligature  to  an  arterial  trunk,  the  consequence  of  w^hicli  is,  that  the 
collateral  arteries  of  the  part  become  increased  in  size,  in  consequence 
of  the  obstruction.  We  shall  see  afterwards,  how  little  tliis  admits  of 
being  proved.  He  says — "  It  is  not  known  how  far  this  enlarged  state 
of  the  arteries  extends  from  the  seat  of  the  inflammation ;  but,  in  the 
case  of  an  inflamed  finger,  the  pulse  at  the  wrist  of  the  corresponding 
arm  beats  more  strongly  than  it  does  on  the  opposite  one."' 

Such  are  Dr.  Marshall  Hall's  views  of  the  causes  of  inflammation, 
and  the  part  wliich  the  capillaries  and  minute  arterial  vessels  play  in 


54  .  CLINICAL   MEDICINE. 

that  interesting  process.  You  perceive,  by  the  brief  outline  I  have  given, 
that  he  attributes  all  the  phenomena  to  adherence  of  the  blood-globules 
to  the  sides  of  the  capillaries,  the  consequent  obstruction  of  these  vessels, 
and  the  enlargement  of  the  minute  arteries  to  wliich  that  obstruction 
gives  rise.  In  this  view  of  the  case  the  vessels  are  regarded  as  passive, 
and  are  distended  on  purely  mechanical  principles ;  in  fact,  their  en- 
largement is  a  mere  dilatation. 

Notwithstanding  the  respect  I  entertain  for  the  learning,  ability,  and 
industry  of  Dr.  Marshall  Hall,  I  must  say  that  I  look  upon  his  views  as 
purely  hypothetical,  and  am  convinced,  that  he  has  arrived  at  unsound 
conclusions  with  respect  to  the  nature  of  inflammation.  I  shall  not, 
however,  take  up  your  time  by  going  over  his  positions  seriatirn,  and 
showing  their  untenable  characters ;  but  shall  proceed  at  once  to  lay  be- 
fore you  the  opinions  to  wliich  observation  and  reflection  have  led  me; 
and  wliich  have  been  taught  for  many  years  in  my  lectures  on  the  In- 
stitutes of  Medicine.  I  shall  not,  like  Dr.  Marshall  Hall,  attempt  to 
explain  the  nature  of  inflammation,  or  determine  its  proximate  cause, 
but  shall  content  myself  with  endeavouring  to  arrange  its  phenomena, 
and  point  out  their  order,  and  the  share  which  the  capillaries  have  in 
the  inflammatory  process.  Before  entering  on  this  subject,  it  may 
be  necessary  to  premise  a  few  observations  on  the  circulation  in 
general. 

The  human  body  is  composed  of  various  parts,  differing  in  their  ulti- 
mate structure,  chemical  composition,  and  vital  functions.  There  is  a 
very  remarkable  difference  between  muscle  and  areolar  tissue,  and  be- 
tween the  latter  and  nervous  "tissue.  If  we  examine  these  parts  more 
closely,  we  find  them  differing,  not  only  in  their  structural  arrangements, 
but  also  in  the  ingredients  or  materials  of  wliich  they  are  composed.  In 
muscle  we  find  a  large  quantity  of  fibrin  or  colouring  matter ;  in  carti- 
lage, fibrous  membrane,  and  tendinous  substance,  we  find  more  or  less 
of  thefidrous  structure  of  muscle,  but  we  do  not  meet  with  Jidrin,  and 
there  is  not  the  slightest  trace  of  colouring  matter.  The  same  blood 
furnishes  materials  for  the  growth  and  nutrition  of  all,  and  conveys  the 
nutrient  particles  to  red  and  white  tissues  ahke ;  but  the  white  parts  re- 
quire not  red  blood,  and  consequently  receive  none.  Blood  is  a  com- 
pound fluid,  which  contains,  as  it  were,  the  raw  material  of  all  the  tis- 
sues in  a  fluid  state ;  it  is,  in  fact,  flesh  in  a  state  of  fluidity,  and  des- 
tined to  combine  with  and  support  the  solid  portions  of  the  frame.  It 
is  conveyed  by  the  arteries  all  over  the  body,  supplying  each  tissue  with 
its  appropriate  materials,  and  contributing  to  its  growth,  sustentation 
and  repair,  in  the  amplest,  and  yet  in  the  most  economical  manner.  It 
does  not  enter  the  tissue  of  every  organ  in  that  state  wliich  has  been 


THE    CIECULATION    OF   THE    BLOOD.  55 

termed  arterial,  and  in  wliich  it  appears  as  a  fluid  of  a  bright  red  colour. 
Tliis  is  an  error  of  wliich  nature  is  never  guilty.  It  would  be  absurd  if 
aU  parts  of  the  blood  were  carried  to  aU  the  different  tissues  indiscrimi- 
nately ;  and  it  would,  moreover,  be  a  great  waste  of  vital  and  mechani- 
cal power.  The  chief  bulk  of  the  blood  is  made  up  of  a  transparent 
fluid  or  lymph,  holding  in  solution  various  salts,  besides  albumen  and 
fibrin.  The  red  globules  are  immersed,  but  not  dissolved,  in  tliis  fluid ; 
and  it  appears  from  the  observations  of  Mayer,  that  in  the  minute  ves- 
sels the  red  globules  occupy  the  central  part,  surrounded  by  the  trans- 
parent fluid.  The  colouring  globules  are  necessary  for  the  nutrition  of 
muscular,  mucous,  and  some  other  tissues ;  and  are  carried  by  the 
minute  vessels  wherever  they  are  required.  Every  part  of  the  blood  is 
required  in  a  muscle ;  fibrin  and  colouring  matter  for  its  essential  fibre ; 
albimien,  fatty  matter,  &c.,  for  its  areolar  tissue  and  adipose  membrane. 
The  white  tissues,  as  I  have  already  observed,  receive  no  red  blood,  be- 
cause they  require  none — ^this  is  quite  certain.  Serous  membrane,  for 
instance,  contains  neither  fibrin  nor  colouring  matter  :  at  what  point  of 
the  circulation  does  the  separation  of  the  albumen  take  place  ?  Is  it  an 
act  of  nutritive  secretion  wliich  separates  it  from  the  whole  mass  of  ar- 
terial blood,  or  are  only  the  serous  portions  of  the  blood  carried  to  the 
white  tissues  ?  "  Serous  vessels,'^  says  Miiller,  "  that  is,  bloodvessels 
which  are  too  minute  to  allow  the  passage  of  the  red  particles,  and  which 
are  traversed,  therefore,  merely  by  the  lymph  of  the  blood,  may  pos- 
sibly exist,  but  they  have  not  been  demonstrated.^' 

It  seems  to  me,  however,  that  it  is  by  no  means  necessary  for  blood- 
vessels to  be  too  minute  to  allow  the  passage  of  red  globules,  in  order 
to  make  these  vessels  the  vehicles  of  lymph  alone.  The  entrance  of  the 
globules  into  them  will  be  determined  by  other  circumstances  than  their 
size.  Abeady,  as  the  blood  approaches  the  capillary  system,  the  mi- 
croscope detects  a  tendency  to  a  separation  between  its  lymph  and 
colouring  globules ;  and  no  doubt  their  complete  separation  is  efifected 
by  vital  agencies,  independent  of  mere  cahbre.  Hence  we  may  explain 
the  fact,  that  no  red  blood  seems  to  circulate  in  serous  membranes 
during  health ;  but  the  moment  inflammation  sets  in,  the  natural  play 
of  vital  energies  is  deranged,  and  the  red  globules,  finding  their  way  in- 
to unwonted  channels,  vessels  innumerable,  before  filled  with  a  trans- 
parent lymph,  and  therefore  not  visible,  start  suddenly  into  view,  in 
consequence  of  their  now  containing  an  opaque  and  coloured  fluid. 

According  to  Hall,  MiiUer,  and  other  physiologists,  all  minute  vessels 
contain  red  particles,  which,  however,  are  beheved  to  exert  no  influence 
on  their  colour,  so  long  as  these  particles  are  only  admitted  singly,  and 
not  several  at  a  time.      But  when  inflammation  comes  on,  according  to 


56  CLINICAL   MEDICINE. 

Hall  these  vessels  are  enlarged  in  consequence  of  obstruction,  and  then 
admitting  a  greater  proportion  of  red  globules,  become  visible.  Now, 
gentlemen,  observe  how  suddenly,  when  the  conjunctiva  connected  with 
the  sclerotic  is  irritated,  numerous  vessels  appear  filled  with  red  blood. 
Here  is  no  time  for  the  adhesion  of  globules  to  the  internal  surfaces  of 
the  vessels — no  time  for  the  gradual  enlargement  of  vessels  previously 
too  small  for  the  admission  of  the  red  globules ;  no,  the  vessels  existed 
there,  but  they  contained  no  red  globules ;  they  admitted  none,  because 
their  admission  would  have  proved  unnecessary  or  injurious.  I  do  not 
deny  the  sudden  enlargement  of  minute  vessels ;  on  the  contrary,  I  be- 
lieve in  it  most  firmly,  and  am  persuaded  that  the  minute  and  capillary 
arterial  branches  which,  in  health,  admit  only  lymph,  may  suddenly  ex- 
pand and  increase  in  size.  I  do  not,  for  reasons  hereafter  to  be  detailed, 
consider  this  expansion  as  passive ;  and  I  believe  that  the  red  globules 
made  Httle  or  no  part  of  the  fluid  previously  circulating  in  these  vessels. 
Indeed,  it  seems  rather  illogical  to  argue  that,  because  red  globules 
might  be  present  without  imparting  a  perceptible  red  colour  to  tliis  fluid, 
that,  therefore,  they  are  present.  When  the  contents  of  a  vessel  are  to 
the  eye  colourless,  the  onusprohandi  lies  with  him  who  asserts  the  presence 
of  red  colouring  matter ;  and,  until  that  is  proved,  in  each  particular 
case,  the  contained  fluid  must  be  regarded  as  colourless. 

As  to  the  idea  that  lymph  vessels  could  not  exist  unless  their  diameter 
was  smaller  than  that  of  the  red  globules,  it  is  too  mechanical  to  deserve 
serious  attention.  The  entrance  of  animal  matters  into,  and  their  pro- 
pulsion along  vessels,  depend  most  assuredly  on  other  conditions  than 
mere  size  of  particles.  Indeed,  Miiller  expressly  says — "  In  the  most 
minute  capillaries  which  are  not  red,  nor  even  yellow,  but  quite  trans- 
parent, there  is  merely  a  single  line  of  red  particles,  separated  by  unequal 
intervals,  and  from  time  to  time  no  red  ^particles  are  seen  in  these  colour- 
less vessels  ;  but  I  have  seen  no  canals  through  wliich  red  particles  did 
not  occasionally  pass,  and  which,  therefore,  deserved  the  name  of  vasa 
serosa,  and  Wedemeyer,  who  says  he  has  seen  such  vasa  serosa  himself, 
confesses  that  some  of  the  red  bodies  traversed  them  from  time  to 
time.'^  Here,  then,  we  have  my  argument  confirmed  by  observation, 
and  the  fact  proved,  that  the  entrance  and  passage  of  the  red  jparticles 
does  not  depend  on  the  mere  size  of  the  vessels. 

If  we  take  an  accurate  view  of  the  general  circulation,  we  shall  find, 
then,  that  there  is  a  great  circulation  of  red  fluid  containing  the  raw 
material  of  all  the  tissues ;  wliich  fluid,  in  its  integral  state,  is  destined 
cliiefly  for  the  muscles  of  voluntary  and  involuntary  motion,  into  every 
part  of  wliich,  red  vessels  penetrate,  and  from  which  red  blood  returns. 
In  fact,  red  blood  forms,  as  it  ^vere,  a  separate  circulation,  sweeping  by 


THE    CIECULATION    OF    THE    BLOOD.  57 

the  white  tissues,  to  which  it  merely  detaches  its  uncoloured  lymph, 
while  the  red  blood  enters  the  capillaries  of  the  red  tissues.  When  the 
minute  arteries  arrive  at  the  parts  where  red  blood  is  no  longer  neces- 
sary, they  send  off  smaller  vessels  which  contain  only  white  blood,  mixed 
with  comparatively  few,  if  any,  red  globules,  while  the  branches  which 
carry  red  blood  proceed  to  join  the  corresponding  veins. 

I  dissent  from  the  common  notion  that  the  circulation  of  the  blood 
goes  on  very  rapidly.  It  has  been  computed  that  the  heart  expels  from 
two  to  four  ounces  at  each  stroke  of  the  left  ventricle ;  and  if  we  com- 
pute the  quantity  of  blood  in  the  body  to  be  from  twenty  to  thirty 
pounds,  we  shall  be  led  to  conclude  that  the  whole  mass  of  the  blood 
passes  through  the  heart  in  a  very  short  space  of  time.  This,  however, 
is  only  taking  a  partial  view  of  the  matter.  It  is  true  that  there  is  a 
rapid  central  current  of  red  blood  which  accomplishes  its  circle  through 
the  body  in  a  very  short  time,  but  a  large  proportion  of  the  juices  of 
the  body  circulates  very  slowly  through  the  tissues  it  supplies,  being 
detained  in  the  capillary  system  for  a  considerable  period  before  it  is  re- 
turned to  the  general  mass  of  the  circulation.  If  you  compare  the  rela- 
tive circulations  of  different  classes  of  animals,  you  will  find  that  they 
differ  considerably  in  the  composition  of  their  blood,  as  well  as  the  rate 
at  which  it  travels  through  the  system.  Some  animals  have  only  white 
blood  and  a  capillary  circulation — without  any  distinct  arteries  or  veins. 
Others  possess  vessels  corresponding  to  arteries  and  veins — but  still  no 
distinct  organ  hke  the  heart.  Einally,  we  arrive  at  a  higher  class,  which 
has  not  only  distinct  arteries  and  veins — but  also  a  heart.  In  each  of 
these  classes  the  circulation  differs,  not  only  in  the  properties  of  the 
circulated  fluid,  but  also  in  the  velocity  with  which  it  travels.  It  is 
much  slower,  much  more  sluggish,  in  the  lower  than  in  the  upper  classes 
of  animals.  In  the  same  way,  blood  does  not  circulate  so  rapidly  in  tis- 
sues of  a  low  degree  of  organization  (as  bone,  cellular  and  fibrous  mem- 
brane), as  in  the  red  parts  of  the  body.  It  is,  therefore,  not  unreason- 
able to  suppose  that  bone  lives  at  one  rate,  fibre  at  another,  muscle  at 
another,  and  nervous  matter  differently  from  all.  These  views  are  of 
importance  when  brought  to  bear  on  the  subject  of  inflammation,  and 
tend  to  explain  the  slow  progress  it  makes  in  certain  tissues. 

You  must  have  perceived  that,  from  the  very  beginning,  I  have  re- 
jected the  idea  that  the  blood  is  propelled  through  the  system  by  the  vis 
a  tergo  alone.  If  that  were  the  case,  the  current,  though  diminisliing 
in  velocity  as  it  receded  from  the  heart,  would  be  equable  in  vessels  of 
the  same  size  throughout  the  whole  system.  But,  in  my  opinion,  the 
current  of  circulation  has  many  different  rates,  which  depend  not  on 
the  vis  a  tergo  alone,  or  the  distance  from  the  heart  and  size  of  the 


58  CLINICAL   MEDICINE. 

vessels,"*^  but  on  the  vital  energy  of  the  vessels  themselves.  Hear  what 
Miiller  says  on  this  subject : — "  Wedemeyer^s  description  of  the  course 
of  the  blood  in  the  anastomosing  capillaries  agrees  perfectly  with  what 
I  have  observed.  Sometimes,  he  says,  the  red  particles  flow  rapidly 
from  one  current  into  another,  as  if  by  attraction.  In  other  cases  the 
current  which  they  join  is  very  rapid,  but  they  are  arrested ^  as  itwere^  in 
the  collateral  current y  and  07ily  from  time  to  time  find  means  of  entering . 
Sometimes  a  red  particle  is  even  thrown  back  out  of  the  rapid  current 
into  a  weaker  stream,  and  is  again  repelled.  I  have  also  remarked  that 
the  same  anastomosing  branch  between  two  currents  sometimes  receives 
the  blood  in  one  direction,  and  sometimes  in  the  other,  and  that  va- 
riation^ of  pressure  and  position,  and  motions  of  the  animal,  are  always 
the  causes  of  these  changes.''' 

Such  is  Midler's  testimony  concerning  the  circulation  in  the  capilla- 
ries, and  it  bears  me  out  in  the  assertion,  that  a  very  great  portion  of 
blood  (using  that  word  in  its  most  comprehensive  sense,  and  meaning 
thereby  nutritive  fluid)  j  is  comparatively  stagnant  in  the  capillary  sys- 
tem ;  but  I  must  confess  that  I  felt  much  astonished  at  MuHer's  asser- 
tion, that  "all  these  variations  in  the  capillary  currents  are,  just  as  in  cur- 
rents of  water  ,on  irrigated  land,  merely  the  results  of  mechanical  causes." 

Having  made  these  preliminary  observations,  we  are  now  better  pre- 
pared to  speak  of  the  forces  by  means  of  which  the  circulation  of  blood 
is  accomplished.  Most  authors,  and  with  them  Miiller,  have  stated 
that  the  motion  of  the  blood  in  the  capillaries  is  wholly  dependant  on 
the  heart's  action.  Now  these  vessels  are  mere  simple  membranous 
tubes,  and  there  is  no  doubt  that  their  membranous  parietes  must  exert 
a  strong  power  of  endosmosis  and  exosmosis,  as  shewn  by  Dr.  Rogers, 
in  the  American  Journal  of  Medical  Science.  This  power  must  neces- 
sarily have  a  great  influence  on  the  motions  of  the  blood  contained  in 
the  capillaries,  causing  a  mutual  interchange  of  contents  between  vessels 
in  contact  with  each  other,  and  between  the  vessels  and  surrounding 
parenchyma  of  the  organs.  Again,  it  has  been  proved  by  Dr.  Draper, 
in  the  same  journal,  that  in  capillary  tubes  and  organic  pores  a  motion 
of  the  contents  must  result  when  the  contained  fluid  possesses  certain 
physical  properties,  from  its  mere  contact  with  the  internal  surface  of 
vessels  so  minute. 

Here,  then,  are  two  sources  of  motive  power,  quite  independent  of 
the  heart's  action,  and  which  must  necessarily  influence,  in  a  most  im- 

♦  The  blood's  velocity  in  its  progress  from  the  heart  is  diminished  chiefly  by  two  phy- 
sical causes,  viz.  increase  of  friction,  and  the  increasing  capacity  (considered  as  a  whole), 
of  the  vessels  which  contain  it. 


THE   VASCULAR   SYSTEM.  59 

portant  manner,  the  capillary  circulation  :  but  this  is  not  all,  for  there 
resides  in  the  small  vessels  connected  with  the  capillaries,  whether  mi- 
nute arteries  or  minute  veins,  a  vital  sensibility  which  enables  them,  by 
suddenly  or  gradually  changing  their  cahbre,  to  increase  or  diminish 
the  quantity  of  fluid  in  any  particular  organ  or  tissue. 

Facts  in  abundance  may  be  brought  forward  in  proof  of  this  asser- 
tion. When  a  fatty  or  fleshy  tumour  arises  on  any  part  of  the  body,  we 
have  new  vessels,  as  it  were,  created ;  and  there  is  no  reason  to  attri- 
bute their  formation  to  any  thing  like  a  dilating  vis  a  tergo.  But  the 
formation  of  the  vascular  system  in  the  foetus  affords  the  strongest 
proofs.  Here  the  smaller  and  more  minute  parts  are  formed  first,  the 
development  commencing  with  the  capillaries,  and  extending  to  the 
minute  arteries  and  veins,  and  then  to  the  larger  trunks ;  until,  at  last, 
the  heart  is  superadded,  at  first  of  an  elementary,  afterwards  of  a  com- 
plicated structure. 

The  best  account  of  the  development  of  the  vascular  system  in  the  foetus, 
is  contained  in  Yon  Baer^s  work,  published  in  1837,  in  Konigsberg."^  He 
says  (Part  II.  p.  126),  that  there  is  no  doubt  that  the  blood  is  formed  be- 
fore the  vessels.  The  formation  of  blood  goes  on  in  every  part  of  the 
body,  and,  when  formed,  it  is  put  in  motion  by  the  agency  of  some  un- 
known cause  which  impels  it  in  the  proper  direction,  until  it  at  length 
reaches  the  central  formation  of  blood,  around  which  is  developed  a  tu- 
bular canal,  afterwards  to  be  further  modified  and  changed  into  the 
heart.  In  truth  the  first  motions  of  the  blood  are  towards  the  heart, 
and  consequently  the  first  vessels  formed ,  are  the  veins  ;  a  fact  in  itself 
sufficient  to  disprove  the  hypothesis  that  this  motive  power  which  pre- 
sides over  the  circulation  resides  exclusively  in  the  ventricles  of  the 
heart.  What  do  we  find  occurring  in  the  case  of  pseudo-membranes 
resulting  from  pleuritic  inflammation  ?  Exactly  what  takes  place  in  the 
development  of  the  foetus.  A  large  quantity  of  lymph  is  efiiised,  which 
at  first  has  no  vascular  connexion  whatever  with  the  parietes  of  the 
chest.  After  some  time,  however,  the  effused  lymph  becomes  organized, 
and  vessels  begin  to  form  in  its  substance  ;  these  extend  gradually,  and 
join  the  vessels  of  the  tissue  with  which  the  lymph  lies  in  contact.  Of 
this  formation  of  vessels  in  effused  lymph  there  can  be  no  doubt ;  I 
have  often  examined  it  with  admiration,  and  it  is  likewise  attested  by 
Andral.  When  a  mass  of  lymph,  effused  into  the  pleural  cavity,  is 
about  to  organize  itself,  and  become  vascular,  a  vast  number  of  red 
points  make  their  appearance  throughout  the  mass,  and  are  connected 
with  very  minute  streaks,  having  a  vascular  distribution.   -In  this  lymph, 

*  Uber  Entwickelung  geschichte  der  Thierc,  &c.  &c. 


60  CLINICAL   MEDICINE. 

then,  red  blood  is  manufactured,  as  in  the  foetal  body  at  an  earlier 
period  of  development,  and  vessels  are  formed ; — and  sanguineous  cir- 
culation, no  doubt,  exists. 

These  facts,  I  say,  bear  strongly  on  the  question  before  us,  proving 
beyond  a  doubt  that  the  vital  properties  of  living  matter  are  capable  of 
forming  vessels,  and  of  rapidly  increasing  their  size  when  formed.  To 
account  for  the  sudden  increase  in  the  size  of  vessels  belonging  to  an 
inflamed  part,  we  must  look  to  this  fact,  and  not  rely  solely  on  increased 
vis  a  tergo,  aided  by  obstruction. 

Now  the  whole  of  Dr.  Marshall  Hal?s  explanation  depends  on  these 
two  causes — vis  a  tergo,  and  obstruction.  But  I  say  that  vessels  may 
be  formed,  multiplied  and  enlarged,  independently  of  these  causes,  and 
in  consequence  of  an  altered  vital  action  of  the  parts  in  wliich  the  process 
occurs.  Let  me  refer  to  the  case  of  the  impregnated  uterus.  In  the 
unimpregnated  state,  the  womb  is  a  small  organ,  with  vessels  and  nerves 
so  small  as  scarcely  to  admit  of  being  satisfactorily  traced.  What  takes 
place  after  conception  ?  It  has  now  new  and  important  functions  to 
perform,  and  it  becomes  proportionally  increased  in  magnitude  and  vi- 
tal activity ;  its  arteries  and  veins  become  elongated  and  enlarged ;  its 
walls  become  thickened,  and  its  nerves  increased  in  size.  And  yet  we 
are  told  that  this  increase  in  the  size  of  its  vessels  depends  on  obstruc- 
tion. Where  does  the  obstruction  exist  ?  What  proof  have  we  that 
there  is  any  increased  vis  a  tergo  ?  Will  any  of  these  principles  account 
for  the  augmented  size  of  its  nerves  ?  l^edemann  has  proved  beyond 
contradiction  that  the  nervous  matter  of  the  womb  is  augmented  to  a 
very  remarkable  degree,  during  the  impregnated  state,  and  that  minute 
nervous  filaments,  scarcely  discoverable  with  the  aid  of  a  microscope, 
enlarge  into  bands  visible  to  the  naked  eye.  The  same  thing  occurs 
with  respect  to  the  minute  arteries  and  veins ;  from  being  but  barely 
perceptible,  they  become  large  tortuous  vessels  carrying  an  abundant 
supply  of  blood,  and  performing  their  functions  with  extraordinary 
activity.  I  do  not  pretend  to  offer  any  explanation  of  these  facts ;  I 
merely  place  them  before  you,  and  show  you  the  analogy  which  exists 
between  the  vascular  and  nervous  development. 

The  vessels  increase  in  size  and  capacity,  so  do  the  nerves ;  and  the 
augmented  size  and  capacity  of  both  depend  on  the  same  unknown 
cause.  The  nerves  are  developed  in  the  same  order  as  the  vessels,  and, 
like  the  latter,  they  increase  from  the  circumference  to  the  centre.  Nay, 
I  am  persuaded,  that,  did  our  means  of  investigating  the  nerves  possess 
the  same  advantages  as  those  we  enjoy  in  the  examination  of  the  vessels, 
we  should  find  that,  in  inflamed  parts,  the  nervous  matter  increases,  in 
many  cases,  as  rapidly,  and  to  as  considerable  an  extent,  as  the  vascular. 


THE    CAPILLARY    CIRCULATION.  61 

So  far,  gentlemen,  I  have  endeavoured  to  lay  before  you  proofs  of 
the  independence  of  the  capillary  circulation,  a  fact  which  I  have  long 
since  brought  forward  in  my  public  lectures,  and  of  which  I  have  written 
somewhat  in  detail,  in  my  review  of  Dr.  Joerg's  work  on  Atelektasis  of 
New-born  infants.  These  views,  I  am  happy  to  state,  have  been  further 
confirmed  by  Dr.  Houston,  in  his  essays  published  in  the  tenth  and 
twenty-fourth  volumes  of  the  Dublin  Journal.  In  these  essays,  which 
I  recommend  to  the  attentive  perusal  of  every  student.  Dr.  Houston 
gives  an  account  of  an  extraordinary  case  of  twins  bom  of  a  healthy 
young  woman,  between  the  seventh  and  eighth  month  of  her  pregnancy. 
One  of  the  children  was,  to  aU  outward  appearance,  perfect  in  every 
particular,  and  of  the  full  growth  of  its  age  ;  the  other,  a  female,  and 
the  subject  of  Dr.  Houston^s  communication,  was  a  monster,  of  some- 
what smaller  size  than  its  companion.  Both  were  alive  at  the  time  of  deli- 
very, but  died  almost  immediately  after.  There  was  a  separate  cord,  and 
a  separate  set  of  membranes,  for  each  foetus.  The  abnormal  one  had 
neither  brain,  heart,  lungs,  nor  liver ;  the  kidneys  were  of  enormous 
size,  nearly  filling  the  abdomen,  and  extending  to  the  apex  of  the  cavity 
formed  by  the  ribs. 

The  umbilical  vein,  after  quitting  the  cord,  descended  between  the 
abdominal  muscles  and  peritoneum  as  far  as  Poupart's  ligament,  and 
there  opened  into  the  external  iliac  vein,  which  became  enlarged  in  size 
at  this  point.  From  tliis  vein  all  the  veins  of  the  body  were  derived ; 
large  branches  passed  to  the  pelvis,  thighs,  and  kidneys,  and  smaller 
ones  to  the  intercostal  spaces,  and  the  tumour  which  constituted  the 
head.  These  veins  were  devoid  of  valves,  and  terminated  in  the  capilla- 
ries. From  the  latter,  the  arteries  began  by  fine  roots,  and  gradually 
coalescing,  united  into  a  sort  of  aorta  on  the  forepart  of  the  spine, 
wliich  descending,  divided  into  the  iliac  and  hypogastric  arteries  in  the 
usual  way.  No  communication  existed  between  the  arteries  and  veins, 
except  at  their  capillary  terminations. 

Such  is  the  history  of  this  very  remarkable  case,  as  given  by 
Dr.  Houston.  I  have  not  time  at  present  to  enter  into  his  arguments ; 
but  I  think  he  has  satisfactorily  proved,  that  in  this  instance  the  cir- 
culation was  carried  on  without  the  aid  of  the  heart  of  the  other  twin  (as 
supposed  by  Sir  Astley  Cooper),  or  of  the  heart  of  the  mother,  and  that 
it  depended  solely  on  the  vital  energy  of  the  capillary  and  other  vessels. 

Another  case  of  a  monster  without  a  heart,  is  related  in  the  American 
Journal  of  Medical  Science,  for  February,  1838,  by  Dr.  Jackson,  of 
Boston.  This  was  likewise  a  twin ;  and  there  can  be  but  little  doubt 
that  its  circulation  was  quite  independent  of  any  assistance  derived  from 
the  heart  of  its  fellow. 


62  CLINICAL  MEDICINE. 

I  have  already  spoken  of  the  dilatation  of  the  arteries  and  veins  of 
inflamed  parts,  as  being  produced  by  something  very  different  from 
mere  distention ;  and  that  it  is  not  of  a  passive  but  an  active  nature. 
That  the  larger  vessels  actively  dilate  can  scarcely  be  doubted  by  any 
one  who  has  observed  the  state  of  the  temporal  arteries  in  phrenitis,  or 
apoplexy ;  that  the  veins  have  a  similar  power,  may  be  observed  on 
plunging  the  hands  or  feet  into  a  hot  medium,  whether  moist  or  dry. 
Blisters  appHed  to  the  skin  produce  for  the  time  increased  size  of  the 
cutaneous  veins ;  and  sores  on  the  leg  may,  when  considerable  and  of 
long  duration,  give  rise  to  a  varicose  state  of  the  veins.  When  a  grain 
of  sand  falls  into  the  eye,  how  sudden  is  the  redness — ^how  numerous 
the  vessels  which  now  appear  gorged  wdth  blood  !  This  change  takes 
place  in  a  few  seconds,  and,  in  my  opinion,  can  be  most  satisfactorily 
accounted  for,  by  supposing  that  the  capillaries  and  smaller  vessels  enjoy 
a  wide  range  of  size,  if  I  may  use  the  expression,  and  are  capable  of 
enlarging  or  diminishing  their  calibre,  according  to  the  exigencies  of 
the  case  and  the  state  of  the  circulation.  That  the  large  arteries  and 
veins  do  so,  is  acknowledged  by  all,  and  is  proved  by  arterial  trunks 
contracting  on  their  contents  so  as  to  maintain  their  proper  tension ;  no 
matter  how  much  blood  is  drawn  from  an  animal.  The  larger  veins  are 
capable  of  a  like  contraction  and  expansion :  can  similar  properties  be 
denied  to  the  smaller  arteries,  possessing,  as  they  do,  an  elastic  coat 
proportionably  thicker?  The  vascular  phenomena  attending  a  blush 
ought  to  have  taught  physiologists  how  rapidly,  how  instantaneously, 
blood  may  be  drawn  to  a  particular  part,  and  may  again  desert  it ;  and 
that,  under  circumstances  where  the  vis  a  tergo  could  not  determine  a 
flow  of  blood  to  the  part  in  question,  more  than  to  any  other  in  the 
body.  Do  we  need  microscopic  examinations  on  the  capillaries  of  re- 
cently killed  animals  to  instruct  us,  when  such  phenomena  offer  them- 
selves, as  it  were,  for  the  very  purpose  of » illustration  ?  When  the 
child  breathes  for  the  first  time  the  air  admitted  into  the  lungs  gives 
new  energy  to  their  capillaries,  and  at  once  the  great  current  of  blood 
flows  through  the  pulmonary  arteries,  deserting  the  ductus  arteriosus. 
In  a  seven  months'  child  the  latter  passage  is  still  very  large ;  and  yet, 
when  the  child  breathes,  its  being  open  effects  very  little,  if  any  thing, 
towards  diminishing  the  flow  of  blood  into  the  pulmonary  arteries. 

Here,  again,  we  observe  how  arteries  grow  independently  of  mere 
pressure  from  within ;  for  the  pulmonary  arteries  and  pulmonary  veins 
are  enlarging  themselves  long,  long  before  they  are  called  on  to  be 
channels  for  a  quantity  of  blood  at  all  proportioned  to  their  calibres. 
John  Hunter  observed  the  enlargement  of  the  arteries  of  an  inflamed 
part,  and  his  observations,  and  those  of  others,  have  brought  to  light 


EFFECTS   OF   INFLAMMATION   ON   THE   CIRCULATION.  63 

a  periodical  and  remarkable  increase  in  the  size  of  the  vessels  destined 
to  promote  the  growth  of  the  stag's  honis.  Are  we,  in  this  case,  to 
explain  that  enlargement  by  obstruction,  or  by  the  vis  a  tergo  ?  It  is 
impossible  to  do  so ;  and  we  must,  then,  look  to  the  vessels  of  the  part 
itself  for  a  solution  of  the  question.  In  such  instances,  as  in  the  case 
of  the  pregnant  uterus,  these  vessels  are  endowed  with  this  power  of 
growth  and  enlargement,  quite  independently  of  the  general  vascular 
system,  or  the  action  of  its  centre — the  heart. 

I  am  the  more  anxious  to  impress  on  you  this  view  of  the  subject,  as 
the  hypothesis  of  obstruction  has  been  adopted  by  many  late  writers,  as 
explanatory  of  the  local  changes  of  circulation  attending  inflammation. 
Thus  Dr.  Williams,  in  his  admirable  lectures  published  in  the  Medical 
Gazette i  (No.  528),  says,  ^' We  cannot,  in  the  present  state  of  patho- 
logical knowledge,  doubt  that  the  circulation  through  the  inflamed 
vessels  is,  to  a  certain  degree,  obstructed;  whilst,  either  as  a  conse- 
quence of  this,  or  from  some  co-operating  influence,  the  vessels  leading 
to  the  part  become  dilated,  and  being  thus  more  open  than  others  to  the 
pulse-wave  of  the  heart,  they  become  the  seat  of  that  throbbing  hard  pulse 
that  has  been  mistaken  for  increased  action  of  the  vessels  themselves." 

Now,  gentlemen,  you  observe  here  that  Dr.  Williams  expresses  him- 
self doubtfully  about  the  dilatation  of  the  vessels  being  caused  by 
obstruction,  and,  he  even  speaks  of  some  co-operating  influence.  We 
shall,  therefore,  content  ourselves  with  having  recited  his  opinion  on 
this  subject.  I  must  observe,  however,  that  the  dilatation  of  the  ves- 
sels, however  caused,  can,  on  no  principle,  account  for  their  becoming 
the  seat  of  tlii'obbing,  and  a  hard  pulse :  their  being  more  open  than 
others  to  the  pulse-wave  from  the  heart,  could,  at  the  utmost,  only 
place  them  in  the  situation  of  other  arteries  naturally  of  the  size  they 
have  now  attained  to ;  but  we  do  not  find  that  such  arteries  tln-ob,  or 
have  a  hard  pulse.  Arteries  do  not  throb,  or  become  the  seat  of  a 
hard  pulse,  in  proportion  to  their  size.  That  is  not  the  fact ;  and,  con- 
sequently, Dr.  WiiHams's  explanation  cannot  be  admitted. 

Dr.  Weatherhead,  who  has  arrived  at  very  nearly  the  same  view  of 
the  subject  with  myself,  says,  "  The  first  effect  of  an  excitant,  or  irri- 
tant, applied  to  any  part  of  the  body,  is  to  attract  the  blood  to  the  seat 
of  irritation,  and  to  quicken  its  current  in  the  capillaries .'''  So  far  we 
perfectly  agree.  Here  Dr.  Weatherhead  estimates  the  vital  energy  of 
the  vessels  of  the  part  at  its  true  value,  and  does  not  call  in  the  aid  of 
an  increased  vis  a  tergo  to  account  for  an  augmented  determination  of 
blood  to  any  particular  locality ;  but  to  what  foUows  I  cannot  accede. 
"  If  these  effects  be  kept  up  beyond  a  certain  period,  or  carried  beyond 
a  certain  degree,  the  excitation  continues  to  attract  as  much  blood  as 


64  CLINICAL   MEDICINE. 

before,  while  the  power  of  the  capillaries  to  forward  it  diminishes,  bj  the 
exhaustion  ensuing  from  their  prolonged  over  action."  There  seems  but 
a  weak  analogy  in  support  of  the  assertion,  that  increased  vascular 
action  must  necessarily  produce  vascular  exhaustion. 

It  may  be  objected  to  my  view,  that  dilatation  of  an  active  nature 
cannot  be  conceded  to  the  capillaries,  whose  coats  are  quite  thin  and 
membranous ;  but  when  the  objects  are  so  minute,  it  is  quite  impossible 
to  determine  the  physical  or  vital  powers  of  tissues ;  and  we  should  re- 
collect that  what  is  deficient  in  degree  may,  in  the  case  of  capillaries, 
be  made  up  by  their  number,  which  is  immense  in  every  part  of  the 
body.  Still,  so  far  as  our  observations  do  go,  they  seem  to  establish 
the  property  in  question."^ 

Miiller,  whose  opinion  on  all  physiological  questions  is  of  the  greatest 
weight,  has  adopted  on  this  subject  an  hypothesis  which  appears  to  me 
to  be  quite  untenable.  It  is  observable,  that  the  first  of  the  following 
paragraphs,  which  I  quote  from  his  work,  proves,  that  when  writing 
it,  he  felt  conscious  that  the  remarkable  phenomena  of  vital  turgescence 
are  totally  irreconcileable  with  the  theory,  which  denies  any  permanent 
circulating  power  but  that  of  the  heart,  and  which  asserts  that  "  the 
motion  of  the  blood  in  the  capillaries  is  wholly  dependent  on  the  heart's 
action !"  Let  us  hear  what  he  says  concerning  vital  turgescence  of  the 
blood-vessels : — "  Although  it  be  denied  that  the  circulation  is  in  any 
way  aided  by  an  attraction  between  the  blood  and  the  capillaries,  yet 
the  existence  of  such  an  attraction  or  affinity  may  be  admitted  in  the 
instance  of  the  turgescence,  turgor  vitalis,  or  orgasm,'  observed  to 
take  place  in  certain  parts  of  the  body,  which  are  the  seat  of  increased 
vital  action,  independently  of  the  action  of  the  heart.  This  condition 
of  turgescence  is  very  evident  in  plants :  thus  to  the  fruit-bud,  which 
contains  the  impregnated  ovum,  there  is  as  Burdach  remarks  an  afflux 
of  sap  :  ubi  stimulus,  ibi  affluxus. 

"The  mutual  vital  action,  or  affinity  between  the  blood  and  the  tissues 
of  the  body,  wliich  is  an  essential  part  of  the  process  of  nutrition,  is, 
under  many  circumstances,  greatly  increased ;  and  gives  rise  to  an  accu- 
mulation of  blood  in  the  dilated  vessels  of  the  organ.  It  is  seen,  for  ex- 
ample, in  the  genitals,  during  the  state  of  sexual  desire,  in  the  uterus 
during  pregnancy,  in  the  stomach  during  digestion,  and  in  the  processes 
of  the  cranial  bones  on  which  the  stag's  antlers  afterwards  rest,  at  the 

*  It  is  only  this  very  year  that  physiologists  have  for  the  first  time  admitted  that  the 
middle  coat  of  arteries,  besides  elastic  tissue,  is  provided  with  muscular  fibre.  The 
discovery  of  this  fact  is  due  to  the  investigations  of  Henle,  and  has  been  confirmed  by  the 
electro-magnetic  experiments  of  Ed.  and  E.  H.  Weber.  Supplement  to  Miiller's  Phy- 
siology^ hy  Baly  and  Kirkes.    1 848.  p,  2. 


INFLAMMATION — THE   CIRCULATION.  65 

time  of  the  reproduction  of  these  parts.  The  local  accumulation  of  blood, 
with  the  dilatation  of  old,  and  the  formation  of  new  vessels,  is,  however, 
seen  most  frequently  in  the  embryo,  in  which  new  organs  are  developed 
in  succession  by  a  process  of  this  kind ;  while,  on  the  other  hand,  other 
organs,  such  as  the  branchiae  of  the  salamander  and  frog,  and  the 
tail  of  the  latter  animal,  become  atrophied  and  perish  as  soon  as 
the  vital  affinity  which  existed  between  the  blood  and  their  tissues 
ceases  to  be  exerted. 

"The  phenomena  of  turgescence  have  been  supposed  to  depend 
on  an  increased  action  or  contraction  in  the  arteries.  But  arteries  pre- 
sent no  periodic  contractions  of  a  muscular  nature ;  and  a  persistent  con- 
traction of  the  arteries,  unless  it  were  progressive  or  vermicular, 
or  aided  by  valves  arranged  in  a  determinate  direction,  would  be  quite 
inadequate  to  produce  a  state  of  turgescence  in  any  part. 

"  To  explain  the  state  of  orgasm  of  the  uterus  during  pregnancy, 
and  of  the  bony  processes  which  bear  the  antlers  of  the  stag,  we  must 
presuppose  the  existence  of  an  increased  affinity  between  the  blood  and 
the  tissue  of  the  organ.  This  condition  may  be  excited  very  suddenly, 
in  the  instantaneous  injection  of  the  cheeks  with  blood,  in  the  act  of 
blushing,  and  of  the  whole  head,  under  the  influence  of  violent  pas- 
sions ;  in  both  of  which  instances,  the  local  phenomena  are  evidently 
induced  by  nervous  influence.  The  active  congestion  of  certain  organs 
— of  the  brain,  for  example — while  they  are  in  a  state  of  excitement,  is 
a  similar  phenomenon. 

"  If  the  organ  which  is  susceptible  of  the  increased  affinity  between 
the  blood  and  the  tissue  is,  at  the  same  time,  capable  of  considerable 
distention,  tumefaction  and  erection  take  place.^'"^ 

It  will,  I  believe,  be  readily  acknowledged,  that  MiiUer's  explanation 
is,  after  aU,  a  mere  hypothesis.  Is  this  affinity  between  the  blood  and 
the  tissues  of  the  body  chemical  ?  or  is  it  a  mutual  vital  action  ?  If 
the  latter,  then  the  vessels,  thet/  heing  the  only  tissues  in  contact  with 
the  blood,  are  active,  contrary  to  his  previous  hypothesis.  As  to  the 
chemical  explanation  of  a  blush,  it  surely  does  not  merit  examination. 

The  facts  referred  to  by  MiiUer  in  the  above  passage,  all  tend  to  cor- 
roborate the  view  I  have  adopted,  and  shew  that  local  changes  of  nu- 
trition, vascularity,  and  circulation,  may  be  quite  independent  of  the 
heart's  action. 

We  must  next  turn  our  attention  to  the  increase  in  size  of  some  of 
the  larger  arteries. 

"  Apply  a  ligature,'^  says  Dr.  Hall,  "  to  the  principal  artery  of  a 

•  Mullet's  Physiology,  translated  by  W.  Baly,  m.d.  2nd  ed.,  vol.  1.,  p.  238. 
VOL.    I.  '  5 


QQ  CLINICAL   MEDICINE. 

limb,  the  circulation  is  then  carried  on  by  the  collateral  branches,  which 
become  enlarged  for  this  very  purpose,  and  in  consequence  of  the  ob- 
struction." Now  let  us  study  the  phenomena  a  little  more  accurately, 
and  we  shall  soon  see  how  erroneous  is  this  explanation. 

In  the  first  place,  what  are  the  physical  results  produced  by  tying 
one  of  the  large  arteries  of  a  limb  ?  The  vis  a  tergo,  or  propelling 
power  of  the  heart,  continues  just  as  before ;  the  quantity  of  fluid  or 
blood  within  the  whole  system  of  arterial  tubes  is  unchanged,  while  the 
forces  to  be  overcome  by  the  circulating  power  remain  also  the  same. 
In  fact,  all  the  general  physical  conditions  are  unaltered  after  the  liga- 
ture has  been  applied,  except  that  a  portion  of  the  blood  can  no  longer 
enter  the  tied  artery. 

Let  us  now  investigate  what  effects,  this  non-entrance  of  a  certain 
portion  of  the  blood  into  its  accustomed  channel,  is  likely  to  produce 
on  the  rest  of  the  arterial  system.  When  the  principal  artery  of  a  limb 
is  tied,  the  blood  circulating  in  the  remaining  arteries  of  the  body  and 
the  other  arteries  of  that  limb,  is  pressed  more  strongly  against  the 
arterial  parietes.  But  as  the  distending  force  resulting  from  this  in- 
creased pressure  is  not  confined  to  any  particular  artery  of  the  body, 
but  affects  all,  more  or  less,  it  is  obvious  that  a  power  so  extensively 
distributed  and  subdivided  can  exert  but  little  distending  influence  on 
any  individual  artery,  or,  in  other  words,  can  tend  but  little  to  dilate 
any  of  the  arterial  tubes.  Now  it  is  obvious,  from  the  laws  of  hydro- 
statics, that  this  increased  pressure  will  be  more  exerted  in  proportion 
on  the  main  collateral  arteries  of  the  limb,  than  on  the  smaller ;  it  wiE, 
in  truth,  be  scarcely  sensible  in  the  latter,  and  yet  these  are  the  very 
arteries  which  enlarge  first  after  the  operation  for  aneurism.  The  in- 
crease in  the  size  of  the  arteries  commences,  not  where  it  ought  to 
commence  if  it  depended  merely  on  dilatation  from  increased  pressure, 
viz.  in  the  larger  arteries  and  in  the  collateral  branches  close  to  the 
ligature,  but  it  commences  in  the  smaller  and  more  distant  arterial 
ramifications.  In  addition  to  the  fact  that  a  proportionally  less  pressure 
is  thrown  on  the  smaller  arteries,  we  must  recollect  that  the  latter  have 
parietes  much  thicker  in  proportion  to  their  calibre,  than  the  larger 
branches.  This  is  another  material  objection  to  Dr.  HalFs  explanation 
of  their  increase  in  size. 

What  are  the  phenomena  observed  after  applying  a  ligature  to  an 
artery  of  large  size,  where  a  sufficient  collateral  circulation  may  be  sup- 
plied ?  Pirst,  the  sudden  diminution  of  circulation  in  the  parts  below 
the  ligature  gives  rise  to  coldness  and  paleness  of  the  limb ;  but  in  a 
few  hours  the  circulation  gradually  returns,  the  thermometrical  tempe- 
rature of  the  limb  rises,  and  the  activity  of  the  capillary  system  is 


INFLAMMATION THE  CIRCULATION.  67 

greater  than  in  the  natural  condition  of  the  Hmb.  This  excitement 
continues  for  some  time,  and  then  diminishes  to  the  ordinary  standard 
of  health.  In  eight,  twelve,  or  twenty-four  hours  after  the  application 
of  a  hgature  to  the  main  artery  of  a  limb,  we  find  the  skin  of  the  parts 
below  the  Hgature  pale  and  cool,  but  in  a  few  hours  afterwards  its  tem- 
perature rises,  and  it  exhibits  an  evidently  increased  arterial  action. 
Now  it  is  difficult  to  conceive  that  the  main  collateral  branches  have 
been  dilated  in  so  short  a  space  of  time. 

The  mode  in  which  the  phenomena  witnessed  in  this  instance  are 
best  explained,  seems  to  me  to  be  the  following.  When  a  large  portion 
of  the  blood  destined  for  the  supply  of  a  limb  is  cut  off,  all  the  tissues 
of  a  part  so  deprived  receive  a  shock  :  the  muscles,  nerves,  capillary 
vessels — in  fact,  the  vital  functions  of  the  whole — are  more  or  less 
affected.  After  some  time,  however,  the  vital  depression  is  followed  by 
reaction,  and  this  commences  in  the  smaller  arteries  and  capillary  system, 
its  commencement  being  marked  by  uneasy  sensations,  increase  of  tem- 
perature, and  arterial  throbbing.  The  initiative  of  the  restoration  of 
the  circulation  belongs  to  the  extreme  vessels,  which  take  on  an  in- 
creased action,  and  this  is  gradually  extended  to  larger  arteries.  These 
gradually  augment  in  power,  become  enlarged  and  distended,  and  at 
length  the  circulation  of  the  afPected  limb  is  restored  to  a  state  of  effi- 
cacy, equal,  if  not  identical  with  its  pristine  condition.  Now,  you  are 
told  that  the  increased  activity  of  the  capillary  vessels  in  this  instance 
is  referred  to  the  vis  a  tergo  operating  through  the  anastomosing 
branches.  This  is  a  false  assumption.  In  the  first  place,  the  influence 
of  the  heart's  action,  when  the  blood  passes  through  small  anastomosing 
branches,  and  by  circuitous  courses,  must  be  less  powerful  than  before 
the  operation,  when  the  main  channels  remained  pervious.  The  vis  a 
tergo  is  therefore  lessened,  and  yet  the  capillary  distention  is  greater 
than  before  the  operation,  or  in  the  sound  limb. 

In  the  next  place,  this  argument  is  of  more  force,  when  it  is  consi- 
dered that  the  enlargement  commences  in  the  smaller,  and  gradually 
extends  to  the  larger  vessels ;  and  also,  that  in  some  cases  the  branches 
from  the  main  artery,  through  which  the  blood  must  pass,  do  not  be- 
come perceptibly  enlarged.  Thus  Mr.  Hodgson,  in  his  work  on  dis- 
eases of  arteries,  says — "  The  dilatation  takes  place  principally  in  minute 
ramifications.  The  trunks,  and  the  mouths  of  the  vessels  going  off 
above  the  place  of  obstruction  in  the  main  artery,  in  several  prepara- 
tions, did  not  appear  larger  than  in  their  natural  state,  and  in  a  few 
instances  only  a  slight  dilatation  was  perceptible."  From  these  facts  it 
is  obvious  that  the  vessels  least  under  the  influence  of  the  heart  are  the 
most  dilated.     But  the  most  decisive  proof  is  the  return  of  the  capilla- 


68  CLINICAL   MEDICINE. 

lies  and  minute  arteries  to  their  ordinary  size,  at  the  time  when,  the 
larger  branches  being  dilated,  the  vis  a  tergo  should  be  more  operative. 
Hence  it  would  appear  that  the  power  of  distention  resides  in  the 
arteries  themselves,  the  irritation  commencing  in  the  capillaries,  and 
being  sympathetically  propagated  to  the  larger  vessels.  This  is  further 
confirmed  by  the  fact,  that,  if  an  inflamed  part,  or  a  vascular  tumour, 
be  supplied  by  several  arteries,  and  one  of  them  be  divided,  the  others 
will  enlarge. 

It  is  scarcely  necessary  for  me  to  direct  your  attention  here  to  the 
phenomena  which  occur  in  the  erectile  tissues,  as  the  corpora  cavernosa, 
&c.  It  cannot  surely  be  maintained  that  the  sudden  increase  in  the 
afflux  of  blood  to  these  parts  is  owing  to  any  vis  a  tergo j  or  momentary 
augmentation  of  the  propelling  power  of  the  heart.  No ;  tissues  of 
this  kind  enjoy  the  power  of  attracting  to  themselves  an  increased 
quantity  of  blood,  in  virtue  of  the  vital  power  resident  in  them,  and 
not  from  any  peculiar  exertion  of  extraneous  forces.  In  fact,  the 
capillary  vessels  enjoy  the  property  of  actively  dilating,  and  drawing 
the  blood  into  them,  and  this  appears  to  be  one  of  the  principal  causes  of 
the  circulation.  Of  this  there  is  abundant  proof.  It  has  been  observed 
in  vivisections,  that  after  the  heart  has  ceased  to  act,  the  capillary 
vessels  remain  distended ,  and  appear  to  carry  on  their  functions  as  long 
as  any  blood  is  supplied  to  them  from  the  arteries.  It  has  been  also 
remarked,  that  the  larger  arterial  branches  become  first  empty,  then 
the  smaller,  and  finally  the  capillaries.  Dr.  Philip  states,  that  he  has 
observed  the  circulation  of  the  mesentery  to  continue  for  several 
minutes  after  the  heart  had  been  excised.  This  is  the  true  explanation 
of  the  fact,  that  the  arteries  are  so  frequently  found  quite  empty  after 
death. 

One  of  the  strongest  proofs  we  have  of  the  power  which  the  capilla- 
ries possess  of  drawing  blood  to  themselves,  is  derived  from  the  phe- 
nomena observed  in  vascular  tumours.  If  scratched,  or  sHghtly 
wounded,  these  tumours  frequently  bleed  to  an  alarming  extent ;  while 
the  division  of  the  arteries  which  lead  to  them,  and  the  removal  of  the 
whole  mass,  is  attended  with  a  comparatively  small  loss  of  blood.  This 
is  further  exemplified  in  the  familiar  operation  of  opening  the  temporal 
artery.  If  the  artery  be  only  partially  divided,  and  its  connexion  with 
the  capillaries  still  to  a  certain  degree  maintained,  it  bleeds  copiously ; 
but  if  it  be  cut  across,  and  the  connexion  wholly  destroyed,  it  ceases 
to  bleed  altogether.     Professor  Smith,  of  Pliiladelphia,"^  amputated  a 

*  This  fact  is  mentioned  in  a  monograph  which  I  received  from  America  many  years 
ago.  Unluckily  I  have  mislaid  it,  and  cannot  call  to  mind  the  author's  name.  He  ad- 
vocated views  similar  to  those  I  have  here  attempted  to  establish,  and  to  him  I  am  in- 
debted for  the  argument  derived  from  the  placental  circulation. 


INFLAMMATION THE  CIRCULATION.  69 

leg  below  the  knee,  for  dry  gangrene  of  the  foot  and  ankle.  The  great 
arteries  were  found  wholly  altered  in  their  structure,  being,  as  it  were, 
converted  into  tubes  of  bone.  Although  pressure  was  completely  re- 
moved from  the  femoral  artery,  and  no  means  whatever  were  used  to 
suppress  the  hemorrhage,  the  quantity  of  blood  lost  did  not  amount  to 
half  a  table-spoonful.  At  the  same  time  the  action  of  the  heart  was 
vigorous,  and  the  pulse  at  the  wrist  of  the  ordinary  strength  and  fulness. 
Now  in  this  case  some  blood  must  have  been  passing  through  the  tibial 
arteries  before  the  operation,  for  there  was  some  circulation  in  the  leg 
down  as  far  as  the  ankle,  and  the  collateral  arteries,  or  anastomosing 
branches,  were  not  enlarged. 

If  we  refer  to  the  phenomena  of  wounds  which  engage  arteries,  we 
shall  find,  as  I  have  already  stated,  when  alluding  to  the  operation  of 
opening  the  temporal  artery,  that  the  wounded  artery  of  an  injured  Hmb 
bleeds  much  more  than  the  same  artery  of  an  amputated  one.  Hence 
it  is  that  branches  which  would  pour  out  a  large  quantity  of  blood,  if 
merely  wounded,  sometimes  do  not  require  a  ligature  at  all,  although 
their  divided  orifices  open  on  the  surface  of  a  stump.  Another  instance 
in  wliich  the  attracting  power  of  the  capillaries  may  be  seen,  is  in  cases 
where  portions  of  an  amputated  finger  have  again  united,  of  which  we 
have  several  examples.  In  this  case  the  fluids  effused  by  the  upper 
cut  surface  are  absorbed  and  circulated  by  the  vessels  of  the  amputated 
tip. 

But  one  of  the  most  remarkable  proofs  of  the  position  I  have  laid 
down  is  derived  from  the  circulation  of  the  blood  in  the  placenta.  In 
this  instance  the  impetus  which  the  blood  possesses  in  the  umbihcal 
arteries  has  been  attributed  to  the  vis  a  tergo  derived  from  the  heart  of 
the  foetus.  But  after  the  detachment  of  the  placenta,  after  the  birth  of 
the  foetus,  the  pulsation  in  the  cord  ceases,  first  at  the  placenta,  and 
then  at  the  umbilicus  of  the  infant.  After  this  period  a  section  of  the 
cord  is  not  followed  by  any  thing  like  the  amount  of  hemorrhage  which 
might  be  expected  from  the  division  of  vessels  of  such  diameter,  and  in 
many  instances  there  is  no  loss  of  blood  whatever.  Now  why  does  the 
flow  of  blood  cease  in  the  umbihcal  arteries  ?  The  vis  a  tergo  is  as 
powerful  after  birth  as  before,  and  operates  on  blood  in  tubes  free  from 
obstruction.  It  cannot  be  attributed  to  cold,  for  the  circulation  con- 
tinues in  every  part  of  the  infant ;  nor  to  exhaustion,  for  the  foetus  loses 
no  blood,  and  its  circulation  is  now  independent  of  the  mother.  Neither 
is  it  owing  to  the  action  of  the  lungs,  which  are  said  to  divert  the  blood 
from  the  placenta ;  for  although  a  greater  portion  of  blood  is  carried  to 
the  lungs  after  than  before  birth,  yet  this  would  not  account  for  the 
total  cessation  of  the  circulation  in  vessels  so  large  as  the  umbihcal 


70  CLINICAL   MEDICINE. 

arteries.  The  explanation^  therefore  commonly  given  is  not  capable  of 
being  proved.  Trom  the  facts  which  I  have  brought  forward^  it  would 
appear  that  the  organic  vital  actions  of  the  placenta  depend  upon  its 
own  life,  and  that  when  this  body  is  detached  from  the  uterus,  it  of 
course  dies,  and  the  functions  of  its  capillary  system  cease.  The  suction- 
power  of  the  small  vessels  then  continues  no  longer  to  assist  the  vis  a 
tergo  in  carrying  blood  through  the  umbilical  arteries,  and  the  circula- 
tion declines,  first,  at  the  placenta,  and  finally  in  the  umbilical  arteries, 
at  their  junction  with  the  abdomen  of  the  foetus. 


71 


LECTURE  YI. 

INFLAMMATION THE   CAPILLARY    CIRCULATION. 

Gentlemen — I  have  now  laid  before  you  at  some  length  the  arguments 
derived  from  experiments  and  pathology  in  favour  of  the  capillaries 
having  a  direct  influence  on  the  circulation.  Those  which  may  be  bor- 
rowed from  comparative  anatomy  are  still  stronger.  If  we  look  to  the 
vegetable  kingdom,  we  shall  find  that  the  force  with  which  the  sap — 
the  blood  of  plants,  circulates  in  their  vessels  is  very  great.  Hales  and 
Dutrochet  have  proved  this  by  direct  experiment.  If  a  vine  be  cut 
down  in  spring  to  the  distance  of  three  feet  from  the  ground,  it  throws 
out  sap  with  such  a  force  as  to  raise  twenty-one  feet  of  water.  In  other 
experiments  this  power  was  found  capable  of  raising  thirty-two  and  a 
half  inches  of  mercury,  or  thirty-five  feet  five  inches  and  three  quarters 
of  water ;  and  thirty-eight  inches  of  mercury,  or  forty-three  feet  tliree 
inches  and  one  third  of  water.  To  effect  this  prodigious  circulation,  as 
it  takes  place  in  plants,  the  force  must  be  very  great,  for  we  know  that 
it  is  capable  of  raising  from  the  ground  a  large  quantity  of  water,  com- 
bined with  nutritious  principles,  to  the  top  of  the  loftiest  palm  or  forest 
tree — ^in  fact,  to  an  altitude  of  one  hundred  and  fifty  feet. 

Now  in  what  organs  does  this  power  reside  ?  There  is  no  central 
organ  in  plants,  nothing  hke  a  heart — nothing  like  large  arterial  tubes. 
How,  then,  is  the  ascent  of  the  nutritious  fluid  accomphshed  ?  Let  us 
study  the  phenomena  for  a  moment,  and  we  shall  find  sufficient  evidence 
to  satisfy  ourselves  that  the  fluid  circulating  in  each  part  of  the  tree  is 
brought  to  it  chiefly  hy  the  action  of  the  vessel  of  the  part  itself  I  do 
not  mean  to  deny  the  great  power  which  the  spongioles  of  the  roots, 
acting  as  capillary  systems,  exert  in  driving  the  fluids  they  absorb 
through  the  tubular  vessels  of  trees;  this  power  is  no  doubt  aided 
by  the  buds  and  leaves,  whose  capillaries,  when  acted  on  by  a  proper 
temperature,  discharge  their  vital  functions  with  activity,  and  are  capable 
of  drawing  the  sap  to  the  extremities  of  the  branches.  Thus  in  the 
case  of  a  vine  observed  by  Eicherand,  one  brandi  of  winch  had  crept 


72  CLINICAL   MEDICINE. 

into  a  smith's  sliop,  this  branch  remained  in  leaf,  or  rather  threw  out 
fresh  leaves  in  winter,  while  all  the  other  branches  continued  quite  bare. 
Again,  cut  off  a  branch  of  a  living  plant  and  place  it  in  water,  how 
actively  does  it  absorb  the  water,  and  endeavour  to  prolong  its  existence. 
In  winter  this  attraction  of  the  ultimate  ramifications  of  plants  ceases, 
but  returns  again  with  the  genial  warmth  of  spring,  when  the  buds  begin 
to  expand. 

Phenomena  analogous  to  these  are  also  observed  in  many  animals. 
There  are  numerous  tribes  of  animals  possessing  an  active  circulation, 
which  have  no  heart  whatever.  Thus  the  Medusse  and  Echinodermata, 
which  must  enjoy  an  active  circulation,  as  is  proved  by  their  rapid 
growth,  have  no  heart.  In  the  Holothurio  tubulosa.,  Cuvier  has  traced 
vessels  going  to  the  organs  of  respiration  (pulmonary  arteries),  and 
vessels  coming  from  the  same  (pulmonary  veins),  as  also  a  system  of 
arterial  and  venous  tubes  destined  to  carry  on  the  general  circulation, 
but  no  heart.  There  are  numberless  examples  of  this  arrangement  to  be 
found  in  the  animal  kingdom.  In  fact,  a  great  deal  of  the  motion 
observed  in  the  fluids  of  the  human  body  is  effected  by  other  means 
besides  the  heart,  and  these  means  are  the  powers  possessed  by  the  capil- 
lary vessels  and  membranous  tissues  of  the  body,  which  by  virtue  of  an 
unknown  law,  aid  materially  in  the  circulation. 

You  perceive,  then,  gentlemen,  that  my  views  are  quite  opposed  to 
those  who  assert,  that  in  inflammation  the  enlargement  of  the  capillaries 
is  passive.  Dr.  Hastings  and  Dr.  Philip  allow  that  the  capillaries  dilate 
during  inflammation,  but  they  attribute  this  effect  to  debihty.  This, 
however,  is  a  mere  assumption.  The  plirases,  passive  and  debilitated, 
put  one  in  mind  of  another  hackneyed  expression  founded  alike  on 
fallacy,  namely,  indolent  ulcers.  Now  there  is  nothing  more  active  than 
what  is  termed  an  indolent  ulcer.  It  manufactures  more  secretion,  uses 
more  blood,  and  produces  more  pain  than  any  equivalent  portion  of  the 
same  tissue  throughout  the  body,  and  yet  it  is  termed  indolent !  It  is 
so  Math  regard  to  the  capillaries.  It  is  said  that  in  inflammation  the 
capillary  vessels  are  obstructed,  and  their  force  weakened.  "What  is  the 
real  fact  ?  Take  an  instance  of  conjunctivitis.  What  do  you  observe 
here  ?  The  affected  membrane  is  swollen,  its  nervous  sensibiHty  exalted, 
its  thermometrical  temperature  increased,  its  secretion  augmented.  Are 
any  of  these,  symptoms  of  debility  ?  I  think  they  can  hardly  be  looked 
upon  as  such.  The  increase  of  pain,  heat,  and  fluid  secretions,  the  aug- 
mentation in  size, — aU  the  phenomena,  in  fact,  are  opposed  to  the 
theory  of  debility.  There  is  no  passive  dilatation  or  weakness;  the 
capillaries  enlarge  and  dilate  from  increased,  and  not  from  diminished 
action ;  red  blood  finds  its  way  into  vessels  which  before  received  only 


INFLAMMATION — THE  CIRCULATION.  73 

white ;  and  unusual  secretions  occur  in  tlie  affected  parts.  The  capil- 
laries have  the  initiative ;  with  the7ri  commences  the  enlargement,  which 
afterwards  extends  to  the  smaller  arteries j  and  from  these  to  the  larger 
branches. 

Under  ordinary  circumstances,  the  capillary  circulation  continues 
some  time  after  the  heart  has  ceased  to  beat,  for  the  capillaries  belong 
to  that  class  of  tissues  wliich  possess  an  inferior  degree  of  vitality; 
and  it  has  been  shewTi  by  Bichat  that  such  tissues  survive  those  of  a 
higher  degree  of  organization.  Hence,  the  capillaries  continue  to  act 
for  some  time  after  the  heart  has  ceased  to  beat ;  and  as  it  is  a  law  that 
the  capillaries  of  the  lungs  will  not  transmit  non-arteriahzed  blood,  the 
systemic  veins  become  gradually  distended,  while  the  systemic  arteries 
axe  emptied,  so  that,  after  death,  we  seldom  find  any  blood  in  the  latter. 

A  very  curious  case,  published  by  Dr.  Houston,  supports  very  strongly 
the  views  which  I  have  now  put  forward.  In  this  case  the  circulation 
had  ceased  in  one  of  the  lower  extremities.  The  foot,  and  afterwards 
the  leg,  were  attacked  with  dry  gangrene,  of  which  the  patient  died. 
No  obstruction  was  found  in  the  vessels  after  death,  and  the  ordinary 
injection  passed  readily  into  all  the  arterial  ramifications.  The  arteries 
were  all  pervious,  and  apparently  natural  in  their  texture.  Now,  if  the 
circulation  of  the  limb  had  depended  on  the  arteries  alone,  it  would  not 
have  ceased  so  completely. 

Some  time  ago  I  attended,  with  Mr.  Cusack,  a  patient  from  the  North 
of  Ireland,  a  young  lady  of  rather  dehcate  constitution,  who  was  at- 
tacked at  a  certain  hour  every  day,  in  a  very  singular  way.  The  circu- 
lation in  one  of  her  legs  seemed  almost  to  cease,  and  the  limb  became 
remarkably  pale  and  cold.  This  state  of  the  limb  would  last  for  ten  or 
twelve  hours,  and  then  an  alteration  took  place ;  the  leg  became  hot  and 
painful,  and  its  temperature  became  so  disagreeable  to  the  patient  that 
she  was  obhged  to  keep  the  leg  outside  the  bed  clothes,  and  have  it 
constantly  wetted  with  cold  water  and  vinegar.  During  all  this  time 
the  action  of  the  heart  was  natural  and  the  circulation  of  the  rest  of  the 
body  unaltered.  Here  we  have  a  certain  portion  of  a  limb  at  one  period 
of  the  day  quite  cold  and  pale,  and  at  another  extremely  hot  and  painful. 
How  can  this  be  said  to  depend  on  any  vis  a  tergo  ?  The  true  expla- 
nation of  the  matter  is,  that  it  depends  on  a  periodic  affection  of  the 
nerves,  capillaries,  and  smaller  arteries  of  the  part. 

Before  I  conclude  this  interesting  subject,  I  think  it  well  to  lay  before 
you  the  views  of  some  celebrated  physiologists,  which  coincide  with  my 
own,  and  are  strongly  corroborative  of  the  doctrines  which  I  have  for 
many  years  advocated.  I  shall  first  quote  the  opinions  of  Dr.  Carpenter, 
the  most  modern  and  one  of  the  most  distinguished  of  our  British  phy- 


74  CLINICAL   MEDICINE. 

siologists,  from  the  third  edition  of  his  Treatise  on  Physiology  (page  568) : 
their  importance  is  sufficient  apology  for  quoting  them  in  this  place. 

''  We  now  come  to  the  last  head  of  the  enquiry  into  the  powers  which 
convey  the  blood  through  the  capillary  system — that,  namely,  which 
concerns  the  agencies  existing  in  the  capillaries  themselves.  Many  dis- 
cussions on  this  subject  may  be  found  in  physiological  writings,  and  it 
has  so  immediate  a  bearing  on  one  of  the  most  important  questions  in 
pathology — the  nature  of  inflammation — that  it  deserves  the  fullest 
attention.  The  chief  question  in  debate  is  the  degree  in  which  the 
capillary  circulation  is  influenced  by  any  other  agency  than  the  contractile 
power  of  the  heart  and  arterial  system ; — some  physiologists  maintaining 
that  this  alone  is  sufficient  to  account  for  all  the  phenomena  of  the 
capillary  circulation ;  and  others  asserting  that  it  is  necessary  to  admit 
some  supplementary  force,  wliich  may  be  exerted  either  to  assist,  retard, 
or  regulate  the  flow  of  blood  from  the  arteries  into  the  veins.  We  shall 
first  consider  what  evidence  there  is  of  the  existence  of  any  such  force  : 
and,  when  led  to  an  affirmative  conclusion,  we  shall  examine  into  its 
nature.  No  physiological  fact  is  more  clearly  proved  than  the  existence, 
in  the  lower  classes  of  animals,  as  well  as  in  plants,  of  some  power  inde- 
pendent of  a  vis  a  tergo,  by  which  the  circulating  fluid  is  caused  to 
move  through  their  vessels.  This  power  seems  to  originate  in  them- 
selves, and  to  be  closely  connected  with  the  state  of  the  nutritive  and 
secreting  processes,  since  any  tiling  which  stimulates  these  to  increased 
energy  accelerates  the  circulation,  wliilst  any  check  to  them  occasions  a 
corresponding  stagnation.  It  may  be  convenient  to  designate  this  motor 
force  by  the  name  of  capillary  power,  it  being  clearly  understood,  how- 
ever, that  no  mechanical  propulsion  is  thence  imphed.  On  ascending 
the  animal  scale,  we  find  the  power  which,  in  the  lower  organisms  is 
diffused  through  the  whole  system,  gradually  concentrated  in  a  single 
part, — a  new  force,  that  of  the  heart,  being  brought  into  operation,  and 
the  circulation  placed,  in  a  greater  or  less  degree,  under  its  control. 
Still  there  is  evidence  that  the  movement  of  the  blood  through  the 
capillaries  is  not  entirely  due  to  this,  since  it  may  continue  after  the 
cessation  of  the  hearths  action,  may  itself  cease  in  particular  organs  when 
the  heart  is  still  acting  vigorously,  and  is  constantly  being  affected  in 
amount  and  rapidity  by  causes  originating  in  the  part  itself,  and  in  no 
way  affecting  the  heart.  The  chief  proofs  of  these  statements  will  now 
be  adverted  to. 

'^  When  the  flow  of  blood  through  the  capillaries  of  a  transparent 
part,  such  as  the  web  of  a  frog's  foot,  is  observed  with  the  microscope, 
it  appears  at  first  to  take  place  with  great  evenness  and  regularity. 
But  on  watching  the  movement,  for  some  time,  various  changes  may  be 


INFLAMMATION THE   CIllCULATION.  75 

observed,  which  cannot  be  attributed  to  the  heart's  influence,  and  which 
show  that  a  certain  regulating  or  distributive  power  exists  in  the  walls 
of  the  capillaries,  or  in  the  tissues  which  they  traverse.  Some  of  these 
changes  involving  variations  in  the  size  of  the  capillary  tubes,  have  been 
already  referred  to  ;  others,  however,  are  manifested  in  great  and  sud- 
den alterations  in  the  velocity  of  the  current,  which  cause  a  marked 
difference  in  the  rates  of  the  movement  of  the  blood  through  the  several 
parts  of  the  area  under  observation.  Sometimes  this  variation  extends 
even  to  the  entire  reversion,  for  a  time,  of  the  direction  of  the  move- 
ment, in  certain  of  the  transverse  or  communicating  branches,  the  flow 
always  taking  place,  of  course  from  the  stronger  towards  the  weaker 
current.  Not  unfrequently  an  entire  stagnation  of  the  current  in  some 
particular  tube  precedes  this  reversion  of  its  direction.  Irregularities 
of  this  kind,  however,  are  never  frequent  when  the  heart's  action  is  par- 
tially interrupted ;  as  it  usually  is  by  the  pressure  to  which  the  animal 
must  be  subjected  in  order  to  allow  microscopic  observations  to  be  made 
on  its  circulation.  Under  such  circumstances,  the  varieties  in  the 
capillary  circulation,  induced  by  causes  purely  local,  become  very  con- 
spicuous, for  when  the  whole  current  has  nearly  stagnated,  and  a  fresh 
impulse  from  the  heart  renews  it,  the  movement  is  not  by  any  means 
uniform  (as  it  might  have  been  expected  to  be),  through  the  whole 
plexus  supplied  by  one  arterial  trunk,  but  is  much  greater  in  some  of 
the  tubes  than  it  is  in  others  :  the  variations  being  in  no  degree  con- 
nected with  their  size,  and  being  very  different  at  short  intervals. 

"  The  movement  of  the  blood  in  the  capillaries  of  cold-blooded  ani- 
mals, after  complete  excision  of  the  heart,  has  been  repeatedly  witnessed. 
In  warm-blooded  animals  this  cannot  be  satisfactorily  estabhshed  by  ex- 
periment, since  the  shock  occasioned  by  so  severe  an  operation  much 
sooner  destroys  the  general  vitality  of  the  system ;  but  it  may  be  proved 
in  other  ways  to  take  place.  After  most  kinds  of  natural  death,  the 
arterial  system  is  found,  subsequently  to  the  lapse  of  a  few  hours,  almost, 
or  completely,  emptied  of  blood ;  this  is  partly,  no  doubt,  the  effect  of 
the  tonic  contraction  of  the  tubes  themselves  :  but  the  emptying  is  com- 
monly more  complete  than  could  be  thus  accounted  for,  and  must  there- 
fore be  partly  due  to  the  continuance  of  the  capillary  circulation. 
Moreover,  when  death  has  taken  place  suddenly,  from  some  cause  (as, 
for  instance,  a  violent  electric  shock),  that  destroys  the  vitality  of  the 
whole  system  at  once,  the  arterial  tubes  are  found  to  contain  their  due 
proportion  of  blood.  Further,  it  has  been  ascertained,  that  a  real  pro- 
cess of  secretion  not  unfrequently  continues  after  general  or  somatic 
death ;  urine  has  been  poured  out  by  the  ureters,  sweat  exuded  from 
the  skin,  and  other  peculiar  secretions  formed  by  their  glands ;  and 


7Q  CLINICAL   MEDICINE 

these  changes  could  not  have  taken  place  unless  tlie  capillary  circulation 
were  still  continuing.  In  the  early  embryonic  condition  of  the  highest 
animals,  the  movement  of  the  blood  seems  to  be  unquestionably  due  to 
some  diffused  power,  independent  of  any  central  impulsion  :  for  it  may 
be  seen  to  commence  in  the  vascular  area,  before  the  development  of 
the  heart ;  the  first  movement  is  towards,  instead  of  from  the  centre, 
and  even  for  some  time  after  the  circulation  is  fairly  established,  the 
walls  of  the  heart  consist  merely  of  cells  loosely  attached  together,  and 
can  hardly  be  supposed  to  have  any  great  contractile  power. 

"  The  last  of  these  facts  may  be  said  not  to  have  any  direct  bearing 
on  the  question,  whether  the  capillary  power  has  any  existence  in  the 
adult  condition ;  but  the  phenomena  occasionally  presented  by  the  foetus 
at  a  later  stage  appear  decisive.  Cases  are  of  no  very  frequent  occur- 
rence in  which  the  heart  is  absent  during  the  whole  embryonic  life,  and 
yet  the  greater  part  of  the  organs  are  well  developed.  In  most,  or  aU 
of  these  cases,  however,  a  perfect  twin  foetus  exists,  in  which  the  pla- 
centa is  in  some  degree  united  with  that  of  the  imperfect  one ;  and  it 
has  been  customary  to  attribute  the  circulation  in  the  latter  to  the  in- 
fluence of  the  heart  of  the  former,  propagated  through  the  placental 
vessels.  This  supposition  has  not  been  disproved  (however  improbable 
it  may  seem)  until  recently ;  when  a  case  of  this  kind  occurred,  which 
was  submitted  to  the  most  careful  examination  by  an  accomplished 
anatomist."*^ 

As  the  case  alluded  to,  viz.,  that  by  Dr.  Houston,  is  given  in  the 
preceding  lecture,  I  shall  not  again  introduce  it,  but  pass  on  to  the 
conclusions  which  Dr.  Carpenter,  deduces  from  it.  "  It  is  evident,^'  he 
says,  ''that  a  single  case  of  this  kind,  if  unequivocally  demonstrated, 
furnishes  all  the  proof  that  can  be  needed  of  the  existence,  even  in  the 
highest  animals,  of  a  capillary  power,  wliich,  though  usually  subordi- 
nate to  the  heart's  action,  is  sufficiently  strong  to  maintain  the  circula- 
tion itself,  when  the  power  of  the  central  organ  is  diminished.  In  this, 
as  in,  many  other  cases,  we  may  observe  a  remarkable  power  in  the  living 
system  to  adapt  itself  to  exigencies.  In  the  acardiac  foetus,  the  capil- 
lary power  supplies  the  place  of  the  heart  up  to  the  period  of  birth, 
after  which,  of  course,  the  circulation  ceases  for  want  of  due  aeration  of 
the  blood.  It  has  occasionally  been  noticed  that  a  gradual  degeneration  in 
the  structure  of  the  heart  has  taken  place  during  life,  to  such  an  extent 
that  scarcely  any  muscular  tissue  could  at  last  be  detected  in  it,  without 
any  such  interruption  to  the  circulation  as  might  have  been  anticipated, 
if  it  furnished  the  sole  impelling  force. 

''  It  is  equally  capable  of  proof  on  the  other  hand,  that  an  influence 
generated  in  the  capillaries  may  afford  a  complete  check  to  the  circula-, 


INFLAMMATION THE  CIRCULATION.  77 

tion  of  a  part,  even  when  the  heart's  action  is  unimpaired,  and  no  me- 
chanical impediment  exists  to  the  transmission  of  blood.  Thus,  cases  of 
spontaneous  gangrene  of  the  lower  extremities  are  of  no  unfrequent 
occurrence,  in  wliich  the  death  of  the  solid  tissues  is  clearly  connected 
mth  a  local  decline  of  the  circulation,  and  in  which  it  has  been  shown 
by  examination  of  the  limb  after  its  removal,  that  botli  the  larger  tubes 
and  the  capillaries  were  completely  pervious :  so  that  the  cessation  to 
the  flow  of  blood  could  not  be  attributed  to  any  impediment,  except 
that  arising  from  the  cessation  of  some  power  which  exists  in  the  capil- 
laries, and  is  necessary  for  the  maintenance  of  the  current  tlu*oughthem. 

"  The  influence  of  prolonged  application  of  cold  to  a  part,  may  be 
quoted  in  support  of  the  same  general  proposition ;  for,  although  the 
calibre  of  the  vessels  may  be  diminished  by  this  agent,  yet  their  con- 
traction is  not  sufficient  to  account  for  the  complete  cessation  of  the 
flow  of  blood  through  them,  which  is  well  know^n  to  terminate  in  the 
loss  of  their  vitality.  The  most  remarkable  evidence  on  this  point, 
however,  is  derived  from  the  phenomena  of  asphyxia,  which  will  be 
more  fully  explained  in  the  succeeding  chapter.  At  present,  it  may  be 
stated  as  a  fact  which  has  now  been  very  satisfactorily  ascertained,  that, 
if  admission  of  air  into  the  lungs  be  prevented,  the  circulation  tlirough 
them  will  be  brought  to  a  stand,  as  soon  as  the  air  which  they  contain 
has  been,  to  a  great  degree,  deprived  of  its  oxygen,  or  rather  has  become 
loaded  with  carbonic  acid ;  and  this  stagnation  will,  of  course,  be  com- 
municated to  all  the  rest  of  the  system.  Yet,  if  it  have  not  continued 
sufficiently  long  to  cause  the  loss  of  vitality  in  the  nervous  centres,  the 
movement  may  be  renewed  by  the  admission  of  air  into  the  lungs. 
Now,  although  it  has  been  asserted  that  the  stagnation  is  due  to  a  me- 
chanical impediment,  resulting  from  the  contracted  state  of  the  lungs  in 
such  cases,  this  has  been  clearly  proved  not  to  be  the  fact,  by  causing 
animals  to  breathe  a  gas  destitute  of  oxygen,  so  as  to  produce  as- 
phyxia in  a  difi'erent  manner ;  the  same  stagnation  results  as  in  the  other 
case. 

"  If  the  phenomena  wliich  have  been  here  brought  together  be  con- 
sidered as  establishing  the  existence,  in  all  classes  of  beings  possessing 
a  circulating  apparatus,  of  a  capillary  power  which  affords  a  necessary 
condition  for  the  movement  of  the  nutritious  fluid  through  those  parts 
in  which  it  comes  into  more  immediate  relation  with  the  solids,  the 
question  still  remains  open  as  to  its  nature.  That  the  capillaries  pos- 
sess a  contractile  power,  far  higher  in  degree  than  that  of  the  large  arte- 
ries, and  more  easily  excited  than  that  of  the  smaller,  appears  scarcely  to 
admit  of  doubt ;  though  to  what  it  is  due,  may  be  reasonably  questioned. 
It  has  been  recently  asserted  by  Schwann,  that  they  possess  the  same 


78  CLINICAL   MEDICINE. 

kind  of  fibrous  tissue  in  tlieir  walls  as  do  the  large  vessels ;  and  this 
cannot  be  regarded  as  improbable.  It  is  not  possible,  however,  that 
their  contractility  could  'have  any  influence  in  aiding  the  continuous 
iiTotion  of  blood  tlu-ough  them,  unless  it  were  exercised  in  a  very  diffe- 
rent manner  from  that  of  which  observation  affords  us  evidence ;  for 
when  we  are  microscopically  examining  the  capillary  circulation  of  any 
part,  it  is  at  once  seen  that  the  vessels  present  no  obvious  movement, 
and  that  the  stream  now  rendered  continuous  by  the  elasticity  of  the 
arteries,  passes  through  them  as  through  unelastic  tubes.  The  only 
method  in  which  the  contractility  of  the  capillaries  could  produce  a  re- 
gular influence  on  the  current  of  blood  would  be  an  alternative  contrac- 
tion and  dilatation,  or  a  peristaltic  movement ;  and  of  neither  of  these 
can  the  least  traces  be  discerned.  Hence  we  should  altogether  dismiss 
from  our  minds  the  idea  of  any  mechanical  assistance  afforded  by  the 
action  of  the  capillaries  to  the  movement  of  the  blood.  That  the  con- 
tractile coat  of  the  capillaries  has  for  its  office  to  regulate  the  calibre  of 
the  vessels,  can  scarcely  be  doubted ;  but  any  general  permanent  contrac- 
tion would  only  occasion  an  obstacle  to  the  circulation, — as  is  shown  by  the 
effects  of  stimulating  injections,  which,  if  thrown  into  the  vessels  before 
their  vitality  has  been  lost,  will  not  pass  tlirough  the  capillaries-  It 
would  appear,  therefore,  to  be  through  their  action  on  this  coat  that 
local  stimuli  occasion  a  contraction  of  the  capillaries ;  their  effect,  how- 
ever, is  different  from  what  might  have  been  anticipated  :  for,  instead 
of  the  capillary  circulation  being  retarded,  it  is  accelerated,  at  least,  un- 
til an  abnormal  condition  results  from  their  continued  operation.  Here, 
again,  is  another  evidence,  that  something  different  from  mechani- 
cal power  must  be  the  agent  that  operates  in  all  the  foregoing  cases. 

"  It  appears  from  the  preceding  facts,  that  the  conditions  under 
which  the  power  in  question  uniformly  operates,  may  be  thus  simply 
and  definitely  expressed  ; — whilst  the  injection  of  blood  into  the  capil- 
lary vessels  of  every  part  of  the  system  is  due  to  the  action  of  the 
heart,  its  rate  of  passage  through  those  vessels  is  greatly  modified  by 
the  degree  of  activity  in  the  processes  to  which  it  should  normally  be 
subservient  in  them.  The  current  being  rendered  more  rapid  by  an  in- 
crease in  their  activity,  and  being  stagnated  by  their  depression  or  total 
cessation.  Thus  it  seems  that  '  the  capillaries  possess  a  distributive 
power  over  the  blood,  regulating  the  local  circulation,  independently  of 
the  central  organ,  in  obedience  to  the  necessities  of  each  part.'  If  this 
be  true,  it  is  evident  that  the  dilatation  or  contraction  of  the  capillaries 
wiU  only  have  a  secondaiy  influence  on  the  movement  of  the  blood 
through  them.  The  former  condition  is  usually  an  indication  of  dimi- 
nished vital  energy ;  and  when  it  is  observed,  it  is   almost   invariably 


INFLAMMATION THE   CIRCULATION.  79 

accompanied  by  a  retardation  or  partial  stagnation  of  the  current ;  on 
the  other  hand,  the  application  of  a  moderate  stimulus,  which  excites 
the  contractility,  accelerates  for  a  time  the  motion  of  the  blood,  by 
rendering  more  energetic  that  reaction  between  the  fluids  and  the  sur- 
rounding tissues,  which  is  the  condition  that  really  has  the  most  in- 
fluence over  the  current/' 

In  the  Edinburgh  Medical  and  Surgical  Journal  for  July,  1842,  you 
wiU  find  an  admirable  paper  by  Dr.  Holland,  of  Sheffield,  on  "  The 
Forces  hij  which  the  Blood  is  circulated  in  Capillary  Vessels" 

The  author  goes  through  all  the  arguments  that  have  been  advanced 
to  prove  that  the  circulation  through  these  vessels  is  entirely  due  to  the 
force  of  the  heart,  and  he  shows  most  satisfactorily  how  very  irrecon- 
cileable  such  doctrines  are  with  facts  of  every  day  occurrence.  At  the 
end  of  the  paper  he  mentions  an  experiment,  which  I  believe  to  be 
unobjectionable,  and,  if  possible,  even  more  conclusive  than  Dr. 
Houston's  monster ;  it  proves  beyond  doubt  that  the  circulation  tlirough 
the  capillaries  is  entirely  owing  to  a  vital  property  of  these  vessels,  and 
independent  of  the  influence  derived  from  a  vis  a  tergo.  We  shall 
allow  Dr.  Holland  to  speak  for  himself — "  The  umbilical  vein  conveys 
arterial  blood  from  the  placenta  to  the  foetus,  the  umbilical  arteries 
convey  venous  blood  from  the  foetus  to  this  organ.  The  origin  and 
termination  of  these  two  classes  of  vessels  in  the  placenta  are  involved 
in  much  obscurity.  No  direct  connexion  is  traced  between  them. 
Whatever  opinions  may  be  held  respecting  the  functions  of  this  organ, 
or  its  relation  to  the  uterus,  it  wiU  scarcely  be  doubted  that  the  vein 
terminates  in  capillaries,  and  that  the  arteries  originate  in  the  same 
kind  of  vessels.  It  is  not  our  intention  to  examine  the  phenomena  of 
foetal  circulation,  but  to  allude  only  to  one  striking  peculiarity,  viz., 
the  circulation  of  blood  in  the  umbilical  vein.  This  fluid  is  transmitted 
from  the  placenta  to  the  foetus  without  the  aid  of  any  propulsive  organ. 
The  capillaries  are,  indeed,  the  only  sources  of  motive  power  shown  to 
exist,  and  hence  the  placenta,  separated  from  the  uterus,  appeared 
capable  of  determining  the  influence  of  capillaries,  and  the  efficiency  of 
it  in  urging  the  blood  through  the  long  capacious  vein.  To  institute 
the  experiment  a  placenta  was  procured,  twenty  minutes  after  separation 
from  the  uterus,  and  placed,  with  the  exception  of  the  cord,  in  a  blad- 
der, which  was  immersed  in  water  at  the  temperature  of  100**  Fahren- 
heit. The  free  extremity  of  the  cord,  at  the  same  moment,  was  elevated 
to  an  angle  of  30°,  resting  on  the  edge  of  a  glass,  and  at  the  distance 
of  a  foot  from  the  placenta.  At  the  commencement  of  the  experiment 
no  blood  escaped  from  the  vein,  but  in  two  minutes  from  the  immer- 
sion, it  began  to  flow,  and  continued  for  about  twenty  minutes,  and  at 


80  CLINICAL   MEDICINE. 

this  time  it  was  found  that  the  glass  had  received  above  one  ounce. 
Here,  then/'  continues  Dr.  Holland,  "  is  an  experiment,  much  less 
exceptionable  in  its  character  than  any  with  which  we  are  acquainted, 
demonstrating  the  power  of  the  capillaries  to  carry  on  the  circulation, 
not  only  in  their  own  complicated  net-work  of  vessels,  but  in  larger 
vessels,  and  which  ultimately  terminate  in  a  capacious  vein ;  and  the 
difficulty  to  the  motion  of  the  blood  was  intentionally  increased  by  the 
elevation  of  the  whole  cord  above  the  level  of  the  placenta.  Had  this 
organ  been  immersed  without  the  bladder,  the  absorption  or  imbibition 
of  the  water  would  have  invalidated  the  experiment.  The  water  is  em- 
ployed as  an  external  stimulant  for  the  purpose  of  maintaining,  what 
may  be  conceived  to  be,  the  natural  temperature  of  the  placenta. 

"  The  flow  of  blood  in  this  experiment,  in  our  opinion,  arises  entirely 
from  the  influence  of  the  capillaries.  The  stimulus  of  the  water  causes 
the  blood  to  excite  them  to  contraction,  and  the  escape  of  it  is  not  op- 
posed by  any  impediment.  We  cannot  imagine  that  the  experiment 
produces  any  important  modification  in  the  conditions  of  the  blood. 
The  water  is  not  absorbed,  nor  is  the  temperature  of  it  elevated  above 
the  heat  of  the  body.  The  consideration  of  the  circulation  in  this  case 
is  not  complicated  by  circumstances  acting  a  tergo,  or  in  advance  of  the 
blood ;  nor  by  the  agency  of  respiration,  or  the  struggles  of  an  animal, 
in  torture  or  placed  in  a  constrained  position."*' 

In  Adelon's  "Physiologic  de  THomme,"  vol.  iii.  p.  321,  you  wiU  find 
the  following  remarks  strongly  corroborative  of  my  view  of  the  capil- 
lary circulation. 

"  In  microscopical  observations  on  living  animals,"  he  says,  "  we 
have  seen  the  blood  in  the  small  vessels  not  only  circulating  from 
arteries  towards  veins  through  the  capillary  systems,  mth  such  phe- 
nomena that  its  progress  could  not  be  ascribed  to  the  action  of  the 
heart,  but  often  stopping,  as  if  hesitating  on  the  direction  which  it  was 
to  follow,  and  even  retrograding  with  astonishing  rapidity,  and  for  a 
long  time.  On  irritating  a  white  part,  the  blood  is  observed  aU  at 
once  to  flow  into  the  capillary  system  of  this  part,  and  this  system  ap- 
pears to  exert  a  sort  of  suction  or  absorbing  power  on  this  fluid.'' 

Such,  gentlemen,  are  some  of  the  arguments  in  favour  of  the  sup- 
position that  the  capillary  vessels  exercise  a  remarkable  influence  over 
the  circulation.  There  are  other  proofs  wliich  I  shall  not  touch  on  at 
present,  as  the  more  immediate  business  of  the  hospital  prevents  me 
from  deviating  any  further  from  the  path  of  strict  clinical  investigation. 
You  may  ask,  perhaps,  why  I  have  entered  on  this  subject  at  all,  or 
why  I  have  dwelt  so  long  on  matters  which  appear  to  possess  only  a 
mere  theoretical  interest.     Because  I  am  persuaded  that  much  error 


INFLAMMATION.  81 

exists  with  respect  to  the  nature  of  the  forces  employed  in  carrying  on 
the  circulation,  and  because  I  think  it  of  the  most  vital  importance  that 
you  should  be  in  possession  of  correct  principles  to  guide  you  in  the  nu- 
merous emergencies  attendant  on  the  treatment  of  disease.  The  human 
body  in  its  development  from  a  lower  to  a  higher  degree  of  organization, 
loses  none  of  its  character,  it  ascends,  retaining  in  its  more  perfect  de- 
velopment all  that  is  possessed  in  an  inferior  state.  In  the  first  stage 
of  its  development,  it  possessed  a  diffused  nervous  and  vascular  system. 
It  then  acquired  small  nervous  strings  and  capillary  vessels,  and  finally 
larger  arteries,  larger  nerves,  nervous  centres,  and  a  heart.  In  the 
same  way  its  circulation  commenced,  beginning  in  the  smaller  vessels 
a.nd  extending  to  the  larger,  aided  by  the  vis  a  tergo,  but  independent 
of  it  in  a  remarkable  degree.  Erom  this  view  of  the  subject,  it  follows 
that,  in  many  cases  of  disease,  we  are  to  look  to  the  forces  wliich  regu- 
late the  circulation  of  the  part  afi'ected,  and  not  to  any  vis  a  tergo,  or 
propelling  power  of  the  heart.  The  physician  and  surgeon  must  study 
the  life  of  each  part,  in  attempting  to  estimate  its  morbid  conditions. 
It  was  a  want  of  proper  knowledge  on  this  subject  wliich  led  to  so  many 
errors  in  practice.  Among  these  I  may  mention  the  treatment  of  Egyp- 
tian ophthalmia,  in  wkich  it  was  thought  necessary  to  drain  the  patient 
of  blood,  for  the  purpose  of  subduing  a  mere  local  inflammation.  In 
truth,  the  treatment  of  local  inflammation,  whether  affecting  external 
organs,  as  plilegmon,  carbuncle,  erysipelas,  or  internal  parts,  as  pleurisy, 
peritonitis,  &c.,  can  never  be  properly  understood,  until  the  old  doctrine, 
wliich  (by  teaching  that  the  vis  a  tergo  was  every  tiling  in  inflamma- 
tion) led  to  a  too  general  use  of  venesection,  has  been  laid  aside,  and 
sounder  opinions  adopted. 


VOL.  I. 

4' 


6 


82 


FEVER 


LECTURE  YII. 

FEVEE   IN    IRELAND. EPIDEMIC    OE    1847. 

Before  entering  on  the  treatment  of  Typhus  Eever,  I  wish  to  make 
a  few  preliminary  observations  upon  its  nature  and  peculiar  cha- 
racters. In  the  first  place,  typhus  fever  is  endemic  in- this  country;  at 
no  period,  from  the  earliest  records  down  to  the  present,  has  it  been 
entirely  absent — a  fact  of  which  you  can  easily  satisfy  yourselves  by 
consulting  our  old  authors,  and  by  referring  to  the  annual  reports 
of  the  fever  hospitals,  established  through  different  parts  of  Ireland. 
Eever,  as  I  have  said,  is  always  endemic  in  Ireland,  but  occasionally 
for  one  year  or  one  season,  or  a  succession  of  years  or  seasons,  it  be- 
comes much  more  than  usually  rife,  and  then  is  said  to  be  epidemic. 
In  my  report  of  the  fever  which  devastated  the  west  of  Ireland  in  1822, 
I  advanced  the  opinion  that  such  epidemics  are  consequent  on  great 
dearth  of  provisions,  and  their  unwholesome  quahty.  These  are,  no 
doubt,  aggravating  circumstances,  but  that  they  are  not  the  sole  or 
even  the  cliief  causes  of  typhus  epidemics,  is  evident  from  what  I  have 
since  frequently  witnessed,  viz.  the  occurrence  of  fever  epidemics  dur- 
ing years  of  plenty,  of  which  1826  was  a  remarkable  example. 

The  epidemic  fever  of  the  last  year  (1847)  might,  to  a  superficial 
observer,  appear  an  argument  in  favour  of  the  former  view,  and  both 
immediately  previous  to  and  after  its  commencement,  tliis  doctrine  of 
the  connexion  between  dearth  of  provisions  and  fever  has  been  strongly 
advocated  by  some ;  but,  as  I  shall  show  a  little  further  on,  this,  Hke 
most  epidemic  visitations,  may  be  traced  to  other  and  more  immediate 
causes. 

That  fever,  in  Ireland  at  least,  depends  on  some  general  atmospheric 


IRISH    EPIDEMIC    FEVER.  83 

change,  wliich  affects  the  whole  island  simultaneously,  independent  of 
situation,  aspect,  height  above  the  level  of  the  sea,  dryness  or  moisture 
of  the  soil,  or  any  other  circumstance  connected  with  mere  locality,  is 
proved  by  the  fact,  that  when  typhus  begins  to  increase  notably  in  the 
Dublin  hospitals,  we  may  always  rest  assured  that  a  nearly  simultaneous 
increase  of  fever  will  be  observed  in  Cork,  Galway,  Limerick,  and  Bel- 
fast, as  I  have  on  more  than  one  occasion  ascertained  by  writing  to  the 
Physicians  of  fever  hospitals  in  these  cities. 

For  a  considerable  period  there  was  a  great  tendency  among  physi- 
cians to  refer  the  origin  of  typhus,  and  almost  every  variety  of  fever, 
to  malaria,  or  unwholesome  emanations  from  the  soil,  produced  by  the 
decomposition  of  vegetable  matter.  In  Ireland  facts  do  not  bear  out 
this  hypothesis ;  for,  as  already  stated,  when  an  epidemic  of  fever  has 
become  estabhshed,  it  breaks  out  simultaneously  in  situations  the  most 
different,  and  in  some  where  no  such  emanations  can  be  supposed  to 
exist.  Thus,  I  have  seen  a  whole  family  affected  in  the  telegraph, 
situated  at  the  summit  of  KiUiney,  a  mountain  formed  of  bare  granite, — 
and  indeed  the  granite  and  mountain  districts  beyond  Eathfarnham, 
Tallaght,  and  Killikee,  supply  the  Meath  Hospital  with  its  worst  cases 
of  typhus.  The  malarious  origin  of  fever  in  general,  has,  I  may  re- 
mark, become  much  less  probable  since  the  publication  of  the  official 
documents  connected  with  the  sickness  and  mortality  of  the  British 
troops  in  the  Colonies,  and  from  which,  as  Major  Tulloch  reports,  it 
clearly  appears  that  fevers  of  the  most  malignant  character  frequently 
arise  in  places  presenting,  to  aU  appearance,  a  combination  of  circum- 
stances most  favourable  to  the  exclusion  of  malarious  influence,  while 
fever  is  never  endemic  in  other  stations,  where  all  the  reputed  sources 
of  malaria  exist  together. 

There  can  be  no  doubt  that  in  Ireland,  as  in  other  countries,  the 
effects  of  cultivation  and  drainage  on  the  health  of  the  inhabitants  are 
very  remarkable,  and  I  myself  have  witnessed  several  exemplifications 
of  the  improvement  of  the  public  health  thus  effected.  Formerly  ague 
was  of  rather  common  occurrence  in  some  marshy  districts  in  the  imme- 
diate vicinity  of  Dubhn,  and  consequently  when  I  was  a  pupil,  cases  of 
intermittent  fever  were  constantly  to  be  met  with  in  the  hospitals ;  now 
the  low  grounds  have  been  drained,  and  thus  the  production  of  ague 
has  been  entirely  arrested.  It  may  be  cited  as  a  proof  of  the  former 
frequency  of  ague  in  Dubhn,  that  when  sulphate  of  quina  had  been 
discovered  in  France,  we  in  Ireland  were  among  the  first  British  physi- 
cians who  verified  its  anti-aguish  powers ;  and  Dr.  Barker  and  I,  each 
of  us,  published  tables  of  many  cases  of  ague  cured  in  hospital  by  that 
remedy.     If  I  am  not  mistaken,  tlie  first  dose  of  sulphate  of  quina 


84  CLINICAL   MEDICINE. 

ever  administered  in  Ireland  was  by  myself,  at  the  Drumcondra  Fever 
Hospital. 

It  is  now  generally  admitted  tliat  drainage  greatly  improves  tlie  liealth 
of  the  public ;  and  this  opinion  has  lately  received  additional  support 
from  the  investigations  of  Mr.  Chadwick^  relative  to  the  sanatory  con- 
dition of  the  labouring  population^,  from  whose  work  the  following 
passage  is  extracted  : — 

"  In  considering  the  circumstances  external  to  the  residence  which 
affect  the  sanatory  condition  of  the  population,  the  importance  of  a 
general  land  drainage  is  developed,,  by  the  inquiries  as  to  the  causes  of 
the  prevalent  diseases,  to  be  of  a  magnitude  of  which  no  conception 
had  been  formed  at  the  commencement  of  the  investigation  :  its 
importance  is  manifested  by  the  severe  consequences  of  its  neglect 
in  every  part  of  the  country,  as  well  as  by  its  advantages  in  the 
increasing  salubrity  and  productiveness  wherever  the  drainage  has 
been  skilful  and  effectual.  The  following  instance  is  presented  in  a 
report  from  Mr.  John  Marshall,  jun.,  the  clerk  to  the  union  in  the  Isle 
of  Ely  :— 

"  It  has  been  shown  that  the  Isle  of  Ely  was  at  one  period  in  a  deso- 
late state,  being  frequently  inundated  by  the  upland  waters,  and  desti- 
tute of  adequate  means  of  drainage  :  the  lower  parts  became  a  wilderness 
of  stagnant  pools,  the  exhalations  from  which  loaded  the  air  with 
pestiferous  vapours  and  fogs.  Now,  by  the  improvements  which  have 
from  time  to  time  been  made,  and  particularly  within  the  last  fifty 
years,  an  alteration  has  taken  place  which  may  appear  to  be  the  effect 
of  magic.  By  the  labour,  industry,  and  spirit  of  the  inhabitants,  a 
forlorn  waste  has  been  converted  into  pleasant  and  fertile  pastures,  and 
they  themselves  have  been  rewarded  by  bounteous  harvests.  Drainage, 
embankments,  engines,  and  enclosures  have  given  stability  to  the  soil 
(which  in  its  nature  is  as  rich  as  the  Delta  of  Egypt),  as  well  as  salubrity 
to  the  air.  These  very  considerable  improvements,  though  carried  on 
at  a  great  expense,  have  at  last  turned  to  a  double  account,  both  in 
reclaiming  much  ground  and  improving  the  rest,  and  in  contributing 
to  the  healthiness  of  the  inhabitants.  Works  of  modern  refinement 
have  given  a  totally  different  face  and  character  to  tliis  once  neglected 
spot ;  much  has  been  performed — much  yet  remains  to  be  accomplished 
by  the  rising  generation.  The  demand  for  labour  produced  by  drainage 
is  incalculable;  but  when  it  is  stated  that  where  sedge  and  rushes 
existed  but  a  few  years  since  we  now  have  fields  of  waviug  oats  and  even 
wheat,  it  must  be  evident  that  it  is  very  great. 

"  On  reference  to  a  very  perfect  account  of  the  baptisms,  marriages, 
and  burials,  in  Wisbeach,  from  1558  to  1826,  I  find  that  in  the  decen- 


EFl'ECTS    OF    DRAINAGE    ON    HEALTH.  85 

nial  periods  of  which  1801^  1811^  and  1821  were  the  middle  years,  tlie 
baptisms  and  burials  were  as  under  : — 

Baptisms.  Burials.         Pop.  in  1801. 

1796  to  1805  1,627    1,535     4,710 

1806  to  1815  1,654    1,313     5,209 

1816  to  1825  2,165    1,390     6,515 

"  In  the  first  of  the  three  periods  the  mortality  was  1  in  3 1  ;  in  the 
second,  1  in  40  ;  in  the  third,  1  in  47  ;  the  latter  being  less  than  the 
exact  mean  mortality  of  the  kingdom  for  the  last  two  years.  (See  Re- 
gistrar-GeneraFs  Second  Eeport,  p.  4,  folio  edition.)  These  figures 
clearly  show  that  the  mortality  has  wonderfully  diminished  in  the  last 
half  century,  and  who  can  doubt  but  that  the  increased  salubrity  of  the 
fens  produced  by  drainage  is  a  chief  cause  of  the  improvement.'' 

Evidence  of  a  similar  nature  is  given  with  reference  to  various  parts 
of  England. 

In  the  reports  given  from  the  parish  ministers  in  the  statistical  ac- 
counts of  Scotland,  the  effects  of  drainage  upon  the  general  health  of 
the  population  are  strongly  marked  in  almost  every  county,  expressed 
in  notes  made  from  an  examination  of  the  returns.  Sutherland — Parish 
of  Eogart :  "  Healthy,  and  a  good  deal  of  draining."  Ear  :  "  Subject 
to  iio  particular  disease ;  a  deal  of  draining."  Eoss  and  Cromarty — 
Alness  :  "  Dry  and  healthy  ;  climate  improved  by  drainage."  It  is  to 
be  understood,  that  drainage  appears  to  form  the  essential  part  of  agri- 
cultural improvement  wliich  is  connected  with  the  improvement  of  health. 
Thus,  the  notes  from  another  parish  in  the  same  country,  Kilmuir 
Wester  and  Suddy,  state  it  as  "  healthy ;  great  improvement ;  scarcely 
an  acre  in  its  original  state,"  Eosmarkie  :  "  Healthy  ;  agriculture 
mucli  improved."  Elgin — New  Spynie  :  "  Healthy ;  much  waste  re- 
claimed, much  draining."  Alves  :  "  Dry  and  healthy,  weU  cultivated ; 
wood  sometimes  used  for  drains."  Banff — Deckford :  "  Healthy,  and 
people  long-lived  ;  much  draining."  Kincardine — Eordoun  :  "  So 
much  draining  that  now  no  swamps ;  formerly  agues  common,  now  quite 
unknown."  Angus  Carmylie  ;  "  Health  improved  from  draining." 
Kinross — Kinross  :  "  Agues  prevalent  sixty  years  ago  in  consequence 
of  marshes,  now  never  met  with."  Oswell :  "  Ague  prevailed  formerly, 
but  not  since  the  land  was  drained."  Perth  Methven  :  "  The  north 
mucli  improved  by  draining."  Eedgorton  :  "  Healthy  ;  no  prevaiHng 
disease ;  ague  was  frequent  formerly,  but  not  since  the  land  has  been 
drained  and  planted."  Money  die  :  "  Healthy ;  an  immense  improve- 
ment by  draining."     Abernyte  :  ^^  Since  the  land  was  di'ained,  scrofula 


86  CLINICAL    MEDICINE. 

rare  and  ague  unknown/'  Monzie  :  "  Healthy  ;  a  good  deal  of  land 
reclaimed."  Aucliterarder  :  "  Mucli  draining,  and  waste  land  re- 
claimed ;  climate  good."  Muckhart :  "  Great  improvement  in  agricul- 
ture ;  ague  formerly  prevalent,,  not  so  now."  MuthiE  :  "  Healthy ; 
much  draining  and  cultivation  extended."  And  similar  statements  are 
made  from  the  rural  districts  in  all  parts  of  the  country. 

Ague  is  the  most  remarkable  disease  engendered  by  a  marshy  state  of 
the  country,  and  consequently  the  disappearance  of  ague  forms  the 
most  easily  noted  and  most  striking  change  in  the  health  of  the  inha- 
bitants produced  by  drainage ;  hence  ague  is  so  often  mentioned  in  the 
above  extract.  There  is  no  doubt,  however,  that  drainage  not  merely 
removes  ague,  but  is  beneficial  to  the  public  health,  in  removing  various 
other  maladies  and  derangements  of  the  health  which  are  observable 
among  the  inhabitants  of  marshy  districts ;  and  the  remark  made  with 
respect  to  Ahernytej  ''  siyice  the  land  was  drained,  scrofula  rare,^  was, 
no  doubt,  founded  on  accurate  observation. 

Numerous  other  statements,  corroborative  of  the  preceding,  might 
be  easily  brought  forward,  but  though  ready  to  allow  the  general  im- 
provement in  the  health  of  the  pubHc  resulting  from  drainage,  improved 
habits  of  cleanhness  and  increased  comforts,  yet  I  cannot  admit  that  in 
Ireland  we  are  to  expect  any  notable  diminution  of  continued  fever 
from  the  operation  of  these  causes.  In  making  this  statement,  you  are 
aware  that  I  am  opposing  the  usually  prevalent  opinion.  The  grounds 
for  my  dissent  have  been  partly  explained  to  you  already,  for,  according 
to  my  observation,  the  increase  or  diminution  of  fever  in  Ireland  arises 
from  some  unknown  general  atmospheric,  or,  if  you  w^,  climatic  in- 
fluences, quite  independent  of  locality;  and,  consequently,  the  most 
improved  and  thorouglily  drained  towns  and  country  districts  are  quite 
as  liable  to  epidemics  of  typhus  as  are  the  most  neglected  and  marshy 
parts  of  our  island.  The  causes  which  occasion  these  epidemics  are, 
on  the  other  hand,  in  no  way  connected  with  the  notable  variations  in 
the  seasons,  for  with  us  the  ravages  of  typhus  are  observed  sometimes 
in  dry,  sometimes  in  rainy  seasons ;  and  its  epidemics  appear  quite  un- 
influenced either  by  the  cold  of  winter  or  the  heat  of  summer.  Other 
complaints  are  obviously  dependant  on  the  physical  characters  of  the 
seasons,  and  I  have  made  the  curious  observation,  that  whenever  the 
weather  in  DubHn  becomes  dry  and  steady,  the  public  becomes  un- 
healthy. This  singular  fact  admits,  perhaps,  of  explanation;  for  so 
habituated  is  the  Irish  constitution  to  rapid  changes  of  temperature, 
wind  and  rain,  that  it  is  placed,  as  it  were,  in  an  unaccustomed,  and 
therefore  unnatural  position,  when  the  weather  is  dry  and  steady. 

Be  this  as  it  may,  the  fact  is  undoubted,  that  fever  is  neither  so 


MORTALITY    FROM    FEVER. 


87 


prevalent  nor  so  fatal  in  any  of  the  western  kingdoms  of  Europe  as  in 
Ireland.  This  opinion  has  been  long  entertained  by  physicians,  and  its 
truth  is  fully  confirmed  by  the  following  extract  from  Surgeon  "Wilde's 
valuable  report  upon  the  table  of  deaths  published  in  the  Eeport  of  the 
Commissioners  of  the  Irish  census  in  1841. 

"  The  total  deaths  from  fever  in  Ireland  during  the  ten  years  included 
between  June,  1881,  and  June,  1841,  afforded  by  the  census  returns, 
amount  to  112,072 — in  the  proportion  of  100  males  to  86*14  females 
being  one  death  in  every  10  5  9  of  the  mortaUty  from  all  causes,  and  one 
in  3*4  of  the  deaths  of  the  total  epidemic  class  of  diseases. 

'^  The  provincial  summaries  afford  the  following  proportions  of  the 
mortality  from  fever,  compared  with  the  total  deaths,  in  the  different 
districts,  and  the  hospitals  and  institutions,  &c. 


PROVINCES. 

RoRAL  District. 

Civic  District. 

Hospitals,  &c. 

Total. 

Epidemic. 

General . 

Epidemic. 

General. 

Epidemic. 

General. 

Epidemic. 

General. 

Lriustrr 
Monster  .     . 

Ul.STKR       ,      . 
CONNAOGHT    . 

1  in  3-25 

—  3-48 

—  3-39 

—  3-27 

1  in  13-02 

—  11-22 

—  11-59 

—  9-54 

1  in  7  23 

—  6-71 

—  4-53 

—  6-97 

1  in  19-55 

—  17-55 

—  12-03 

—  15-64 

1  in  1-09 

—  1-24 

—  1-1 

—  1-2 

1  in  2-52 

—  2-2 

—  2-27 

—  313 

1  in  3-21 

—  3-59 

—  3-32 

—  3-46 

I  in  10-85 

—  10-68 

—  10-81 

—  9-79 

Dublin  City 
Cork  City 
Bklfast   .     . 
Galway    .     . 

Ireland    .    . 

~~ 

— 

Iin8-24 

-  6-77 

-  4-01 

-  7-27 

1  in  21 -36 

—  16-75 

—  10-55 

—  15-98 

1  in  1-1 

—  2-02 

—  1-06 

—  1-06 

1  in  2 -69 

—  3-77 

—  1-38 

1  in  3-01 

—  4-49 

—  2-5 

—  4-91 

1  in  7-68 

—  10-5J 

—  6-14 

—  10-45 

1  in 3-36    Jin  11-28 

1  in  6-41 

1  in  16-78 

linl-14 

1  in  2-4 

1  in  3-4 

1  in  10-59 

From  this  document  it  follows  that  the  mortahty  from  fever  in 
Ireland  amounts  to  a  fraction  less  than  one-tenth  of  the  whole  mortality, 
whereas  in  London  the  fever  deaths  do  not  amount  to  more  than  one- 
fiftieth  of  the  total  deaths.  This  difference  becomes  more  striking  from 
considering  that  deaths  in  Dublin  from  fever  are  actually  nearly  double 
the  deaths  from  the  same  cause  in  London.  The  last  census  made  the 
population  of  London  amount  to  one  million  nine  hundred  thousand, 
while  that  of  Dublin  is  two  hui^red  and  thirty- tliree  thousand. 

The  admirable  papers  of  Dr.  Cowan  have  thrown  much  light  upon 
the  comparative  frequency  of  fever  in  different  parts  of  Britain,  and  his 
tables  prove  that  Glasgow  is  more  unfavourably  situated,  as  regards 
fever,  even  than  Dublin;  for  in  1835,  1836,  1837,  the  deaths  from 
fever  alone  were  412,  841,  2,180,  being,  in  the  relation  to  the  mor- 
tality from  all  diseases,  one  in  15*6,  10,  and  4-7  annually:  but  as  the 
year  1837  was  remarkable  for  a  fearful  epidemic,  this  mortality  is  over 
the  average,  for  Dr.  Cowan  in  another  place  shows,  tliat  while  in 
Glasgow,  with  a  population  of  200,000,  the  annual  average  of  fever. 


8S  CLITsICAL   MEDICINE. 

deduced  from  seven  years,  ending  with  1836,  has  been  1842  cases;  in 
Manchester,  with  a  population  of  228,000,  it  has  been  for  the  same 
period  only  497;  in  Leeds,  with  a  population  of  123,000,  only  274: 
and  in  Newcastle,  with  a  population  of  58,000,  so  little  as  39.  These 
numbers  bring  out,  in  striking  contrast  with  Ireland,  the  immunity 
from  fever  enjoyed  by  large  English  towns,  and  corroborate  the  remark 
already  made,  that  the  eastern  and  central  parts  of  Britain,  enjoying  a 
climate  more  different  from  that  of  Ireland,  so  likewise  are  much  freer 
from  fever  than  the  western  parts  of  Britain,  whose  climate  approximates 
more  to  the  Irish. 

It  is  curious,  that  in  those  towns  in  England  which  have  greater  in- 
tercourse with  Ireland,  as  Liverpool,  Manchester,  Bristol,  typhus  predo- 
minates more  than  in  others  not  similarly  circumstanced.     It  was  on 
this  account  that  Dr.  Lombard^  concluded  that  maculated  typhus  fever 
was  imported  into  England  and  Scotland  by  Irish  labourers,  who  go 
over  in  such  numbers  every  year  to  reap  the  harvest.     But  from  the 
statistical  reports  of  Dr.  Cowan  and  others,  it  appears  that,  as  regards 
Scotland,  this  explanation  is  any  tiling  but  satisfactory,  and  it  seems 
more  probable  that  the  west  of  England,  Scotland,  and  Ireland,  in  which 
the  climate  is  almost  the  same,  possess  the  same  combinations  of  circum- 
^    J    stances  which  produce  typhus.     Nothing,  indeed,  can  be  more  remark- 
I    able  than  the  facility  with  which  a  simple  cold  (which  in  England  would 
J    be  perfectly  devoid  of  danger),  runs  into  maculated  fever  in  Ireland,  and 
c    that,  too,  under  circumstances  quite  free  from  even  the  suspicion  of  con- 
I    tagion— in  truth,  except  when  fever  is  epidemic,  catching  cold  is  its 
j    most  usual  cause. 

Much  has  been  said  and  written  about  epidemics  among  cattle  being 
simultaneous  with  hmnan  epidemics,  and  we  have  the  testimonies  of 
Homer  and  Herodotus  in  support  of  the  popidar  behef.  I  am  quite 
sure  that  various  diseases,  such  as  ague,  remittent  and  bihous  fever,  &c. 
&c.  may  be  brought  on  by  miasmata,  which,  emanating  from  the  earth, 
may  likewise  produce  epidemics  among  cattle.  Mr.  Chadwick's  work 
contains  the  following  striking  statement : — 

"  In  the  course  of  inquiries  as  to  what  have  been  the  effects  of  land 
drainage  upon  health,  one  frequent  piece  of  information  received  has 
.been  that  the  rural  population  had  not  observed  the  effects  on  their  own 
health,  but  they  had  marked  the  effects  of  drainage  on  the  health  and 
improvement  of  the  stock.  Thus  the  less  frequent  losses  of  stock  from 
epidemics  are  beginning  to  be  perceived  as  accompanying  the  benefits  of 
drainage  in  addition  to  those  of  increased  vegetable  production.-" 

*  Dublin  MedicalJournal,  vol.  x. 


CAUSES    OF    EPIDEMICS.  89 

Dr.  Edward  Harrison,  in  a  paper  in  wliicli  lie  points  out  the  con- 
nection between  the  rot  in  sheep  and  other  animg,ls,  and  some  important 
disorders  in  the  human  constitution,  observes  : — 

"  The  connection  between  humidity  and  the  rot  is  universally  ad- 
mitted, by  experienced  graziers  ;  and  it  is  a  matter  of  observation,  that 
since  the  brooks  and  rivulets  in  the  county  of  Lincoln  have  been  better 
managed,  and  the  system  of  laying  ground  dry,  by  open  ditches  and 
under-draining,  has  been  more  judiciously  practised,  the  rot  is  become 
far  less  prevalent.  Sir  John  Pringle  informs  us,  that  persons  have 
maintained  themselves  in  good  health,  during  sickly  seasons,  by  inha- 
biting the  upper  stories  of  their  houses ;  and  I  have  reason  to  believe 
that,  merely  by  confining  sheep  on  high  grounds  through  the  night,  they 
have  escaped  the  rot. 

"  The  late  Mr.  Bak/jwell  was  of  opinion  that,  after  May-day,  he  could 
communicate  the  ro/  at  pleasure,  by  flooding,  and  afterwards  stocking 
his  closes,  while  th/.j  were  drenched  and  saturated  with  moisture/' 

The  sanatory  ^^ects  of  road-cleansing — to  which  house- drainage  and 
road-drainage  ay^  auxihary,  is  it  appears  not  confined  to  the  streets  in 
towns  and  tho/'.oads  in  villages,  but  extends  over  the  roads  at  a  distance 
from  habitations  on  which  there  is  trafiic.  Dr.  Harrison — whose  testi- 
mony has  Jr  Len  cited  on  the  subject  of  the  analogy  of  the  diseases  of 
animals  tjP  those  which  afi'ect  the  human  constitution — in  treating  of  the 
preventyii  of  fever  or  the  rot  among  sheep,  warns  the  shepherd  that, 
althou/ii  he  may  provide  drained  pasture  and  avoid  "  rotting-places  "  in 
the  Mlds,  all  his  care  will  be  frustrated  if  he  do  not  avoid,  with  equal 
cai/.,  leading  the  sheep  over  wet  and  miry  roads  with  stagnant  ditches — 
'hich  are  as  pernicious  as  the  places  in  the  fields  designated  as  "  rotting- 
/places.'^  He  is  solicitous  to  impress  the  fact,  that  the  rot,  i.  e.  the 
typhus  fever,  has  been  contracted  in  ten  minutes,  that  sheep  can  at 
"  any  time  be  tainted  in  a  quarter  of  an  hour,  while  the  land  retains  its 
moisture  and  the  weather  is  hot  and  sultry."  He  gives  the  following 
instance,  amoUgst  others,  of  the  danger  of  traversing  badly  drained 
roads.  '^  A  gentleman  removed  ninety  sheep  from  a  considerable  dis- 
tance to  his  own  residence.  On  coming  near  to  a  bridge  which  is  tlirown 
over  the  Barling's  river,  one  of  the  drove  fell  into  a  ditch  and  fractured 
its  leg.  The  shepherd  immediately  took  it  in  his  arms  to  a  neighbour- 
ing house  and  set  the  limb.  During  this  time,  which  did  not  occupy 
more  than  one  hour,  the  remainder  were  left  to  graze  in  the  ditches  and 
lane.  The  flock  were  then  driven  home,  and  a  month  afterwards  the 
other  sheep  joined  its  companions.  The  shepherd  soon  discovered  that 
all  had  contracted  the  rot  except  the  lame  sheep;  and  as  they  were 
never  separated  on  any  other  occasion,  it  is  reasonable  to  conclude  that 


90  CLINICAL    MEDICINE. 

the  disorder  was  acquired  by  feeding  in  the  road  and  ditch  bottoms." 
The  precautions  appKcable  to  the  sheep  and  cattle  will  be  deemed 
equally  applicable  to  the  labouring  population  who  traverse  such 
roads. 

With  reference  to  this  question  I  may  remark,,  that  although  I  have 
carefully  watched  the  progress  of  fever  in  Ireland  for  more  than  a  quarter 
of  a  century,  I  have  not  been  able  distinctly  to  connect  its  epidemics 
with  any  epizootic  disease, — ^true  it  is,  that  occasionally  typhus  fever  is 
prevalent  at  a  time  that  some  fatal  epidemic  affects  horned  cattle,  pigs, 
and  sheep,  and  from  such  an  occurrence,  an  incautious  reasoner  might 
be  led  to  assume  a  natural  connexion  between  the  two  epidemics  as  both 
proceeding  from  the  one  cause.  A  more  protracted  series  of  observations 
will,  however,  dispel  this  illusion,  for  he  will  then  see  that  the  connexion 
is  only  accidental — of  this  the  years  1841  and  1842,  afforded  a  remark- 
able example ;  for  during  both,  the  cattle  of  Ireland  were  decimated  by 
a  most  malignant  epizootic,  while  during  the  same  period  I  never  recol- 
lect a  greater  immunity  from  typhus  :  in  fact,  the  wards  of  the  Meath 
Hospital  were  often  destitute  of  a  single  specimen  of  that  disease. 

Before  leaving  this  part  of  the  subject,  I  will,  as  I  promised  in  the 
commencement  of  this  lecture,  proceed  now  to  take  a  short  review  of  the 
fever  epidemic  of  last  year  (1847),  more  especially  of  the  causes  by 
which  it  was  produced ;  and  conclude  with  a  summary  of  my  opinions. 

Having  made  some  enquiries  into  the  prevalence  of  fever  in  Ireland  in 
1837-38,  which  I  published  at  length  in  the  14th  vol.  of  the  Dublin 
Jo^irnal  of  Medical  Science ,  I  was  led  to  the  conclusion,  that  the  chief 
causes  of  the  epidemic  diffusion  of  fever  in  Ireland  must  be  of  a  very 
general  and  not  of  a  local  nature,  for  we  find  the  most  exact  agreement 
between  results  observed  in  cities  far  asunder,  and  widely  differing  in 
aspect  and  position.  It  must  have  been  an  influence  coextensive  with 
the  island,  and  acting  every  where  with  a  nearly  equal  degree  of  intensity, 
which  brought  about  this  coincidence,  and  made  fever  attain  its  maxi- 
mum and  minimum  at  the  very  same  time  in  various  places.  It  is  well 
to  keep  in  mind  that  the  establishment  of  the  existence  of  this  epidemic 
influence,  (which  in  Ireland,  even  when  at  its  minimum,  is  but  too  pro- 
ductive,) does  not  preclude  us  from  admitting,  that  many  other  causes 
of  minor  importance  may  in  Ireland  give  rise  to  typhus;  among 
these  we  may  reckon  catching  cold,  fatigue,  mental  emotions,  and 
contagion.  And  the  result  of  last  year's  epidemic  fully  bears  out  this 
conclusion. 

A  vast  amount  of  miscliief  was  produced  by  the  attempt  made  to  con- 
nect fever  epidemics  with  a  deficiency  of  food ;  and  the  great  diffusion, 
the  rapid  spread,  and  the  unusual  mortality  which  characterised  the 


FEVER   EPIDEMIC    OF    1847.  91 

fever  of  1847,  must  be  to  a  great  extent  ascribed  to  tlie  prominence, 
which  from  the  very  first  was  given  to  famine,  as  an  exciting  cause  of 
typhus  fever  in  Ireland.  The  text  put  forth  so  authoritatively,  "if 
there  be  no  famine,  there  will  be  no  fever,''^  prevented  proper  attention 
from  being  paid  to  the  real  causes  which  produce  and  promote  the 
spread  of  epidemic  diseases ;  and  the  means  adopted  to  supply  a  defi- 
ciency of  food  were,  as  I  shall  now  show,  singularly  productive  of  those 
causes. 

Want  of  a  sufficiency,  or  food  of  an  unwholesome  or  improper  cha- 
racter, predisposes  the  human  frame  to  disease  by  its  debilitating  effects 
on  the  system,  and  thus  individuals  become  more  susceptible  to  the  con- 
tagious influence  of  epidemics  when  they  exist ;  but  I  cannot  admit  that 
either  cause  is  sufficient  to  generate  an  epidemic.  Over-crowdings  defi- 
cient ventilation,  and  filth,  are  causes  which  in  themselves  give  rise  to 
epidemic  diseases ;  and  when  to  these  are  added  the  debilitating  effects 
oF^mme,  we  have  a  combination  of  circumstances  extraordinarily  calcu- 
lated to  promote  the  diffusion  of  a  contagious  disease  previously  in  ex- 
istence, and  as  I  have  already  said,  typhus  fever  is  always  endemic  in 
Ireland. 

Owing  to  the  failure  of  the  potato  crop  and  other  concomitant  cir- 
cumstances, there  was  great  want  of  food  in  this  country  in  1845  and 
1S46.  In  the  former  year  there  was  no  remarkable  increase  in  the 
number  of  cases  of  typhus  fever  which  are  at  all  times  to  be  met  with  in 
Ireland,  and  active  measures  were  taken  to  provide  the  people  with  em- 
ployment and  a  sufficiency  of  food.  The  measures  adopted  had  the 
effect  of  congregating  together  large  masses  in  the  open  air  in  a  cold  wet 
season,  and  of  over-crowding  the  poor-houses  and  hospitals  tln*oughout 
the  whole  country  to  a  most  frightful  extent. 

"  Eamine  also,"*'  to  quote  the  words  of  Dr.  Lalor  in  his  grapliic  de- 
scription of  this  epidemic  as  it  prevailed  at  Kilkenny,  "  drove  crowds  of 
half-famished  people  into  our  large  and  more  wealthy  towns  and  cities, 
where  the  means  of  procuring  food  were  more  abundant,  and  the 
wretched  and  over-crowded  lodging-houses,  in  which  this  class  of  persons 
found  shelter,  became  the  foci  of  contagion,  and  of  the  worst  forms  of 
fever.  The  foulness  of  the  atmosphere  was  augmented  by  the  accumu- 
lation of  filth  and  heaps  of  manure  and  human  ordure  in  our  lanes  and 
alleys,  to  an  enormous  and  most  pernicious  extent ;  partly  owing  to  the 
prevalence  of  bowel  complaints ;  partly  to  the  dearness  and  dearth  of 
food,  which  absorbed  all  the  time  and  means  of  our  people  in  providing 
for  present  subsistence ;  and  partly  to  the  inability  or  unwillingness  of 
the  farmers  to  expend  money  in  purchasing  this  manure  for  the  cultiva- 
tion of  a  crop  so  precarious  as  potatoes.      It  was  in  the  neighbourhood 

^e..^w     /^^,_^  ^^^.^    ^    X^^_^    /^     "^^^  / 


^ 


92  CLINICAL    MEDICINE. 

of  such  lanes  and  alleys  too  that  fever  prevailed  chiefly  and  most  fatally 
amongst  the  wealthier  classes/^"^ 

The  congregating  or  crowding  together  of  people,  either  in  the  open 
air  or  in  buildings,  has  been  at  all  times  productive  of  disease.  Thus 
in  the  year  1812  in  the  province  of  Gujerat,  West  Hindostan,  the 
people  crowded  into  the  towns  in  consequence  of  the  great  destitution 
which  prevailed,  when  an  epidemic  broke  out  amongst  them  which 
nearly  decimated  the  people,  but  the  epidemic  was  of  small-pox  and 
not  fever.  But  never,  perhaps,  in  the  history  of  the  world  was 
such  a  fearful  commentary  on  the  effects  of  the  entassement  of 
individuals  witnessed,  as  in  Ireland,  during  the  year  1847.  The  news- 
papers and  periodicals  of  the  day  teemed  with  illustrations  of  the  fact, 
that  the  Irish  epidemic  o/*  1847  had  its  origin  in  the  congregating  to- 
gether large  masses  ofjpeojole  at  j^uhlic  works  and  at  depots  for  the  distri- 
bution of  foody  and  in  the  overcrowding  the  workhouses.  I  shall  now 
proceed  to  bring  before  you  some  of  these  illustrations. 

Let  me  first  refer  you  to  the  report  of  the  Poor  Law  Commissioners, 
published  in  May,  1847.  It  contains  some  fearfully  interesting  par- 
ticulars respecting  the  progress  of  disease  and  mortality  in  Ireland.  It 
appears  on  reference  to  the  report,  that  while  the  total  number  of  deaths 
wliich  occurred  in  the  union  workhouses  in  Ireland,  for  the  week  end- 
ding  the  4th  April,  1846,  amounted  to  159  ;  the  total  number  who  died 
in  the  week  ending  the  3rd  April  ]  847  amounted  to  2,706.  A  more 
fearful  fact  still  is  the  large  increase  of  sickness,  and  the  large  propor- 
tion of  fever.  The  number  of  inmates  had  a  httle  more  than  doubled, 
the  numbers  being  on  the  4th  of  April,  1846 — 50,861 ;  and  on  the 
3rd  April,  1847 — 106,888  ;  but  the  numbers  in  the  hospitals  increased 
from  8,121  to  28,239,  while  the  numbers  in  the  fever  hospitals  increased 
from  864  to  the  fearful  number  of  8,931.  The  most  alarming  fact  dis- 
closed by  these  retm*ns  is  the  rate  of  mortality  which  existed,  and  its 
rapid  increase  from  the  previous  November.  In  April,  1846,  the  weekly 
rate  of  mortality  was  3  in  every  1000  inmates.  In  November  it  showed 
a  decided  tendency  to  rise.  During  the  four  weeks  of  December  it  ran 
up  from  7.4,  to  8.6,  then  to  10  3,  and  then  to  11.  In  January,  1847, 
it  was  1 2.2  the  first  week,  13.3  the  last.  In  Tebruary  it  was  17  the  first 
week,  19.5  the  last.  In  March  it  ranged  from  22  to  20,  and  in  April 
it  rose  to  25 — twenty-five  out  of  every  thousand  died  in  the  last  week 
for  which  there  is  a  return. 

In  one  of  the  local  papers  pubKshed  about  this  time  I  find  the  fol- 
lowing observations  : — 

"  Fever  has  been  slowly  and  steadily  increasing  in  Cork  for  some 
*  Dublin  Quarterly  Journal  of  Medical  Science y  vol.  v.  p.  30. 


FEVER  EPIDEMIC  OF  1847.  93 

months,  and  any  man  who  calmly  perases  the  medical  report  on  the  stale 
of  the  Cork  workhouse,  in  February  last,  will  feel  surprised,  not  that 
fever  has  spread,  with  such  fearful  rapidity,  in  Cork,  but  that  the  tem- 
pestuous sweep,  which  now  appals  its  affrighted  citizens,  was  so  long 
stayed.  In  the  workhouse,  the  inmates  were  put  tliree,  and  four,  and 
five  in  a  bed,  and  in  the  convalescent  ward  of  the  hospital  there  were 
forty-five  beds  for  one  hundred  and  twenty  persons  !  Wliat  result  could 
be  expected  from  such  a  state  of  things  save  that  which  followed  ?" 

In  other  workhouses  also  we  find  the  same  effects  to  have  occurred 
wherever  they  were  overcrowded.  It  was  so  in  Dublin,  in  Fermanagh, 
in  Galway,  in  Limerick,  in  Waterford,  &c.  The  Kilmallock  workhouse, 
built  for  800  inmates,  contained  on  the  27th  of  February  nearly  1,500 
within  its  precints.  The  consequence  was,  that  fever  and  dysentery  be- 
came fearfully  prevalent,  and  the  inmates,  struck  with  terror,  began  to 
leave  the  house,  when  the  Poor-law  Commissioners^  sealed  order  against 
further  admissions  was  received.  That  the  overcrowding  was  the  cause 
of  the  disease  in  this  last  instance  there  can  be  no  doubt,  for  when 
the  inmates  were  reduced  to  1000,  in  the  month  of  April,  the  number 
of  sick  rapidly  diminished. 

The  following  extract  which  I  read  from  a  letter,  received  in  May, 
1847,  from  Dr.  Dillon,  surgeon  to  the  Co.  Mayo  Infirmary,  and  one  of  the 
Poor-law  guardians,  is  strong  testimony  on  this  subject : — "The  Poor-law 
Commissioners  have  given  sad  proof  of  their  ignorance  of  Medical  Police, 
and  total  incompetency  to  direct  or  be  connected  with  the  sanatory  state  of 
the  country — wherever  their  houses  were  in  full  operation,  there  existed 
disease,  and  onl^  there, — we  would  not  open  our  doors  and  congregate 
poverty  and  filth,  when  we  had  not  funds  to  meet  its  expense,  we  were 
dismissed  and  held  up  to  odium,  but,  thank  God,  we  have  spared  human 
life  by  our  decision,  and  have  kept  this  locality  more  free  from  disease  than 
any  other  union  in  the  kingdom,  where  thePoor-Law  was  in  full  operation; 
at  the  same  time,  we  fed  our  poor  by  private  subscriptions,  and  lost 
fewer  from  want  of  food  than  any  other  place." 

It  is  not  my  intention  to  enter  into  a  detailed  historic  account  of  this 
epidemic.  I  am  cliiefly  anxious  to  bring  forward  the  additional  proofs 
which  it  affords  of  the  causes  by  which  the  epidemic  outbreaks  of  typhus 
fever  are  produced  in  this  country,  and  of  the  contagious  character  of 
the  disease.  No  town  in  Ireland  suffered  more  from  this  epidemic  than 
Cork,  and  in  no  town  were  these  causes  more  rife.  I  have  now  shown 
you  to  what  an  extent  the  workhouse  of  that  city  was  overcrowded ;  and 
as  a  consequence  the  number  of  victims  to  fever  and  pestilence  was 
frightful.  From  the  22nd  of  December,  1846,  to  the  24th  of  April, 
1847 — four  months,  2,130  persons  died  in  the  buildings  comprising  the 


94  CLINICAL   MEDICINE. 

union  workhouse.  The  great  increase  set  in  about  that  time  and  con- 
tinued to  the  middle  of  March,  when  the  curative  measures  of  the 
board  began  to  take  effect,  and  a  gradual,  though  somewhat  fluctuating, 
decline  soon  took  place.  The  following  are  the  deaths  for  each  week 
and  month  from  December  the  27th  :— 2nd  January,  50;  9th,  59; 
16th,  60;  23rd,  60;  30th,  91;  total  for  January,  329.  6th  Febru- 
ary, 128;  13th,  164;  20th,  146;  27th,  168;  total  for  February, 
606.  6th  March,  143;  13th,  183;  20th,  171;  27th,  175;  total 
for  March,  672.  3rd  April,  159 ;  10th,  128;  17th,  132;  24th,  104; 
total  to  the  24th  April,  523 ;  making  in  all,  as  above  stated,  the 
almost  incredible  number  of  2,130.  In  the  month  of  May  359  died, 
and  in  June  a  little  more  than  200.  From  this  date,  when  the  num- 
bers in  the  workhouse  were  much  reduced,  and  other  sanatory  precau- 
tions taken,  the  number  of  sick  and  the  proportionate  mortality  rapidly 
diminished. 

Numberless  are  the  instances  in  which  fever  has  been  the  issue 
of  crowding  patients  too  closely.  An  eminent  surgeon,  the  late 
Mr.  Pearson,  when  attached  to  the  Lock  Hospital,  London,  uniformly 
observed  that  fever  prevailed  in  the  establislnuent  w^hen  more  than 
a  certain  number  of  patients  were  placed  in  any  of  the  wards.  Eepeated 
observations  of  this  kind  induced  him  afterwards  to  limit  the  number  of 
beds  in  each  ward,  and  the  consequence  was,  a  complete  absence  of  fe- 
ver from  the  place. 

But  there  were  other  causes  also  ill  operation  in  Cork,  which  promo- 
ted the  spread  of  disease  there.  The  following  extract  which  I  read 
from  a  Cork  newspaper  of  the  day,  presents  us  with  a  view,  you  might 
suppose,  of  a  plague-stricken  town  in  the  middle  ages,  and  not  of  the 
second  city  in  Ireland  affected  with  fever  in  the  middle  of  the  19th 
century  : — "  The  incursion  of  rustic  paupers  into  the  city  stiU  continues 
unabated,  the  only  change  being  that  it  is  less  observable,  as  they  wait 
on  the  outskirts  of  the  town  till  dark,  when  they  may  be  seen  coming 
in  droves,  the  bed-clothes  strapped  to  the  shoulders  of  the  father,  while 
the  children  carry  pots,  pans,  jugs,  old  sacks,  and  other  articles.  On 
an  average,  about  three  hundred  of  these  miserable  creatures  come  in- 
to the  city  daily,  who  are  walking  masses  of  filth,  vermin  and  sickness. 
They  squat  on  straw  in  the  principal  streets,  and  teem  in  the  lanes  and 
alleys,  fruitful  sources  of  contagion  and  disease,  and  if  the  officers  of 
health  are  not  active  and  expeditious  in  cleansing  and  whitewashing,  it 
is  to  be  feared  that  pestilence  will  commit  frightful  ravages  in  those 
densely  peopled  and  iU- ventilated  parts  of  the  town.  The  deaths  in  the 
city,  including  the  workhouse,  jails,  and  other  institutions,  as  well  as 
the  desultory  mortaHty  in  the  streets  from  fever  and  starvation,  average 


FEVER    EPIDEMIC    OF    1847.  95 

at  present  about  500  weekly.  Although  the  Cat  Port  Hospital  was 
opened  on  Monday,  with  accommodation  for  200  patients,  it  is  quite  in- 
sufficient for  the  numerous  fever  cases  seeking  relief,  many  of  the 
patients  lying  on  straw  in  the  street  leading  to  the  hospital.  Another 
hospital  capable  of  receiving  120  patients  is  about  to  be  opened  in  the 
same  neighbourhood.  Whole  families  are  now  to  be  seen  in  the  public 
thoroughfares,  some  stretched  on  straw  in  the  sun,  others  lying  under 
blankets,  aU  disgusting  looking  objects,  and  living  on  the  charity  of  the 
passengers.  Several  batches  of  them  were  to  be  seen  on  Camden-quay 
during  the  week.  Although  exhibiting  every  appearance  of  outward 
wretchedness,  many  of  them  are  impostors,  as  they  have  sums  of  money 
on  their  persons,  and  on  being  referred  to  the  food  depots  for  relief, 
they  indignantly  refuse  it.  The  mistaken  charity  of  the  public  keeps 
those  people  within  the  precincts  of  the  city,  on  which  they  have  no 
claim  \^^hatever,  and  they  should  be  sent  to  their  own  homes,  as  re- 
lief committees  and  soup  depots  are  now  generally  established  through- 
out the  country.  On  Wednesday  a  countrywoman  deserted  her  child, 
which  w^as  a  pitiful  object,  half  naked,  and  full  of  smallpox,  and  left  it 
in  the  middle  of  Patrick-street  as  a  legacy  to  the  citizens.^' 

I  cannot  forbear  reading  for  you  here,  some  judicious  observations 
which  bear  strongly  on  the  subject  I  have  been  discussing,  from  the 
Westminster  Review  for  April,  1847  : — 

"  It  is  most  lamentable  to  see  that  in  the  eagerness  of  impulse  to 
apply  the  principle  of  relief,  there  has  been,  and  continues  to  be,  a 
total  disregard  of  the  mode.  Pestilence  has  followed  in  the  footsteps 
of  benevolence,  and  yet  death  itself  has  awakened  no  suspicion  of  error 
in  the  aid  we  have  given  to  its  fearful  devastations.  We  are  told  of  a 
mortality  in  Irish  work-houses  at  the  rate  of  70,000  per  annnm;  but 
can  it  be  pretended,  with  even  the  appearance  of  plausibility,  that  this 
mortaUty  is  the  result  of  destitution  ?  Are  not  the  inmates  of  work- 
houses at  least  fed,  and  warmed,  and  clothed  ?  Is  there  a  member  of 
the  Health  of  Towns  Association,  who  could  not  tell  the  Government 
that  tliis  heavy  rate  of  mortality  can  only  be  the  consequence  of  over 
crowding,  and  defective  ventilation  ?  And  is  such  over  crowding  and 
defective  ventilation  to  continue  under  a  new  poor  law,  in  the  name  of 
charity,  and  not  to  be  denounced  as  the  agency  of  slaughter  ?  Let  us 
note  here  a  fact  stated  in  the  reports  of  Mr.  Twisleton,  that  as 
late  as  the  17tli  of  October,  29  only  of  the  work -houses  in  Ireland, 
out  of  130,  were  fuU,  or  nearly  fuU;  and  that  in  the  remaining  101, 
there  was  stiU  accommodation  for  34,000  inmates  more  than  had  been 
received.  It  was  not  till  the  Government  expenditure  upon  public 
works  had  created  a  gigantic  army  of  500,000  men  to  swaUow  up  aU 


CLINICAL    MEDICINE. 


the  resources  of  the  country,  that  the  continued  rise  in  the  price  of 
provisions,  and  the  desertion  of  families  by  Uie  able-bodied,  drove  the 
feebler  portion  of  the  whole  population  to  the  work-houses  as  a  last 

refuge.     A  last  refuge  indeed  ! — ^tliere  to  sicken,  and  die 

And  let  us  note  again  the  corresponding  manner  in  which  out-of-door 
pestilence  followed  out-of-door  relief, injudiciously  administered.  A  noble 
lord,  reading  in  the  papers  frightful  tales  of  deaths  by  "  starvation,'^ 
of  which  he  is  at  first  incredulous,  rushes  from  Oxford  to  Skibbereen, 
to  learn  the  real  facts  by  personal  observation.  He  is  taken  to  a  cabin 
containing  thirty  inmates,  aU  dead  or  dying.  He  sees  the  death-cart, 
and  dead  bodies  thrown  into  it  by  callous  assistants  with  indecent  haste. 
He  does  not  inquire  whether  plague  in  a  hovel  could,  by  possibility, 
have  arisen  from  other  causes  than  want.  He  does  not  see  in  Skib- 
bereen a  town  of  the  better  class,  well  situate,  comparatively  prosperous, 
but  become  a  great  centre  for  relief  works — a  focus  for  English  charity 
— and  therefore,  suddenly  overwhelmed  by  an  influx  of  pauperism  from 
the  surrounding  districts,  swarming  into  every  kennel  for  nightly  shelter. 
He  heeds  notliing  of  the  evidence  of  sanatory  reports — not  even  of  the 
old  and  famihar  history  of  the  black  hole  of  Calcutta.  He  reflects  not 
that  to  extend  the  system  may  be  to  deepen  the  abyss  of  misery  it  has 
opened.  He  demands  no  modification  of  eleemosynary  aid,  but  only 
more  of  that  wliich  has  been  afforded ;  and,  struck  with  horror  at  that 
which  he  has  Avitnessed,  he  hastens  back  to  England — to  augment  the 
horrors  V 

Another  mistake  also  made  was  the  sudden  change  from  a  deficient 
and  unwholesome  diet  to  a  full  supply  of  nutritious  food,  which  the 
paupers  were  subjected  to  on  their  admission  into  the  work-houses. 
Any  general  change  from  habitual  and  hereditary  diet,  even  to  better, 
proves  unwholesome,  and  renders  the  human  frame  more  suscep- 
tible to  disease.  In  Cork,  during  the  epidemic,  they  were  obhged  to 
form  an  encampment  for  the  troops,  as  the  recruits,  who  joined  half 
famished,  suffered  much,  and  fell  into  bad  health  from  the  change  of 
diet.  Erom  a  somewhat  similar  cause,  some  years  ago,  one  of  the 
finest  regiments  in  Sweden,  consisting  of  Dalecarlians,  lost  nearly  half 
its  men.  Having  been  ordered  to  the  capital  from  their  own  district, 
the  sudden  change  of  diet  from  their  accustomed  black  bread  and  peas 
to  the  better  and  more  nutritious  food  of  Stockholm  so  completely  un- 
dermined their  health,  that  to  save  the  few  who  escaped  disease,  their 
usual  food  was  again  restored  to  them^ 

The  observations  I  have  already  made,  are  all  proofs  too  of  the  con- 
tagious character  of  this  fever ;  but  its  rapid  spread  to  Liverpool  and 
Glasgow — the  two  cities  in  Great  Britain  in  most  immediate  communi- 

X  '  7  ^  ^ 


FEVER  EPIDEMIC  OF  1847.  97 

cation  with  Ireland — and  its  subsequent  progress  to  British  America 
and  New  York,  by  means  of  the  emigrant  ships,  can  leave  no  doubt 
on  this  subject. 

In  the  beginning  of  May,  1847,  Lord  Brougham  presented  a  petition 
from  Liverpool  to  the  House  of  Lords,  stating  that  103,000  Irish 
paupers  were  accumulated  in  that  town  within  the  last  six  months ;  and 
soon  after  we  find  that  the  Irish  typhus  fever  broke  out  there  in  all  its 
virulence,  causing  very  great  mortality.  Thus,  according  to  the  report 
of  the  Registrar-General  of  Mortahty,  in  England  for  the  quarter  end- 
ing June  30th,  1847,  we  find  that  in  Liverpool,  in  the  district  of  St. 
Martin,  the  deaths  were  661,  being  200  more  than  in  the  corresponding 
quarter  of  the  previous  year — typhus  and  diarrhoea  being  the  prevailing 
diseases;  in  Great  Stewart-street  district,  the  deaths  were  1080,  a  very 
great  increase  of  mortality,  "  owing  to  the  Irish  Fever,  which  raged 
amongst  the  poor."  In  Dale-street  district,  "  deaths  809,  an  increase 
over  the  previous  quarter  of  230,  entirely  owing  to  increase  of  fever 
amongst  the  lower  order  of  Irish — 280  were  from  fever,  and  40  from 
small-pox."  In  St.  Thomas  district,  "the  deaths  (598)  are  very  con- 
siderably above  the  average  this  quarter,  in  consequence  of  the  very 
alarming  increase  of  fever."  In  Mount-pleasant  district,  "  deaths  1,007, 
exceed  the  former  quarter  by  499,  owing  entirely  to  the  great  influx  of 
Irish  paupers  into  Liverpool."  In  Islington  district  the  deaths  were 
466,  an  increase  of  193  over  the  (Corresponding  quarter  of  1846  ;  and 
in  St.  George's  district,  "  the  number  of  deaths  (188)  exceeds  that  of 
any  preceding  quarter,  and  shows  an  increase  over  the  corresponding 
quarter  of  1846,  of  88."  And  in  the  return  for  the  quarter  ending  the 
30th  of  September,  1847,  the  registrar-general  makes  the  following  ob- 
servations on  the  state  of  this  great  city  : — "  In  itself,  one  of  the  un- 
healthiest  towns  of  the  kingdom,  Liverpool,  has  for  a  year  been  the 
hospital  and  cemetery  of  Ireland.  The  deaths  registered  in  the  four, 
quarters  of  1846,  were,  1,934,  2,098,  2,946,  and  2,735;  in  the  three 
quarters  of  1847,  ending  in  September  last,  3,068,  4,809,  and  5,669  ! 
[to  this  I  may  add  the  return,  since  pubHshed,  for  the  last  quarter  of 
1847,  3,725,  making  the  total  mortality  for  that  year,  17,271].,  The 
population  of  Liverpool  was  223,054  at  the  last  census.  It  is  im- 
possible to  represent  more  correctly  than  is  done  by  the  short  notes 
of  the  Registrars,  the  piteous  spectacle  which  this  great  town  presented 
— with  the  floating  lazarettos  on  the  Mersey — the  workhouses  crowded 
with  destitute  paupers — the  three  large  sheds  which  will  hold  300  per- 
sons, nearly  full  of  patients  at  the  present  time,  and  the  fever  getting 
more  prevalent  among  the  upper  classes," 

From  Liverpool  the  typhus  fever  rapidly  spread  throughout  all  the 
VOL.  I.  7 


98  CLINICAL   MEDICINE. 

large  towns  in  England,  and  it  was  chiefly  in  the  over-crowded  towns  of 
the  manufacturing  districts,,  Manchester,  Leeds,  Birmingham,  Sheffield, 
&c.  and  in  London,  that  it  prevailed  most  extensively  and  the  mortality 
was  greatest. 

To  Glasgow  it  was  imported  directly  from  Ireland,  and  there  too 
the  mortality  was  very  great,  the  proportion  of  deaths  far  exceeding 
the  cholera  year.  The  mortality  tables  for  that  city  for  the  year 
ending  December  31st,  1847,  show  that  the  number  of  deaths  was 
18,886,  an  increase  over  1846,  of  7,250  deaths  !  The  great  mortahty 
arising,  it  is  stated,  from  the  frightful  immigration  of  poor  Irish,  from 
whom  fever  spread  throughout  the  community. 

The  number  of  emigrants  who  left  this  country,  in  the  year  1847, 
for  America,  is  calculated  to  have  been  more  than  double  that  of  the 
previous  year,  and,  as  a  necessary  consequence,  the  ships  were  all  not 
only  crowded  \i\xi  pached  with  passengers.  There  was  scarcely  a  single 
ship  in  which  typhus  fever  did  not  break  out  on  the  passage,  and  the 
mortality,  as  we  might  expect,  was  still  greater  than  on  land.  Prom 
authentic  documents  now  before  me,  it  would  appear  that  the  number 
of  Irish  who  emigrated  to  British  North  America,  in  1847,  was,  at  the 
lowest  computation,  74,539 ;  of  these  5,293  are  reported  to  have  died 
on  the  passage ;  8,563  were  admitted  into  the  quarantine  hospital  at 
Grosse  Island,  of  whom  3,452  are  said  to  have  died — an  average  of  40 
per  cent.;  and  of  those  who  were  taken  into  the  marine  and  emigrant 
hospital  at  Quebec,  or  who  had  procured  lodgings  in  that  city  up  to  the 
9th  of  October,  there  died  1,041,  an  aggregate  of  9,786  deaths,  up  to  the 
period  of  the  survivors  leaving,  for  Montreal,  an  average  of  over  12 
per  cent.  From  the  account  which  we  have  had  of  the  losses  of  indivi- 
dual ships,  I  am  quite  sure  that  this  statement  is  anything  but  over- 
drawn. The  "  Ceylon,"  with  257  steerage  passengers,  had  30  deaths 
and  115  in  fever  on  her  arrival.  The  "Loosthank,"  wdth  349  steerage 
passengers,  had- 117  deaths,  and  only  20  escaped  fever.  Three  vessels 
taken  together  lost  275  passengers.  The  return  of  the  health-officers  at 
New  York  shows  an  aggregate  of  957  deaths  at  sea  on  board  of  vessels 
coming  from  European  ports,  and  likewise  that  three-fourths  of  the  num- 
ber admitted  into  the  quarantine  hospital  (most  of  them  Irish),  have 
been  taken  from  British  vessels. 

Convincing  proofs  these  facts,  of  the  causes  of  Irish  typhus  fever  and 
of  its  contagious  character !  In  fine  I  may  state  that  from  an  attentive 
consideration  of  the  last,  and  of  previous  epidemics  of  fever  in  Ireland,  I 
have  arrived  at  the  following  conclusions.  1st.  That  epidemics  of  fever 
may  occur  in  Ireland  without  any  scarcity  of  food, — as  proved  by  the 
history  of  many  of  our  past  epidemics.    Eor  information  on  this  subject 


EPIDEMIC  FEVER  OF  1847.  ^ 

I  would  refer  especially  to  the  commentary  of  Mr.  Wilde  on  the  Go- 
vernment census  of  1841,  and  published  in  the  Commissioners'  report. 
2nd.  That  a  scarcity  may  coincide  with  an  epidemic.  3rd.  As  an 
epidemic  of  fever  occurs  at  short  intervals,  and  famine  is  unfortu- 
nately not  less  frequent,  it  consequently  follows  that  an  epidemic  ten- 
dency to  fever  must  frequently  coincide  with  a  visitation  of  famine. 
4th.  In  1847,  as  no  epidemic  had  occurred  for  several  years,  the 
chances  of  coincidence  were  greater  still.  5th.  The  contagious  cha- 
racter of  the  typhus  fever  of  Ireland  was  further  proven  by  the  late  epi- 
demic;— barristers  and  solicitors  returning  from  circuit  brought  the 
fever  to  town  with  them.  I  had  at  one  time  five  from  Gal  way  under 
my  own  care  in  Dublin;  and  Mr.  Eynd  informed  me  that  in  the 
convict  depot  aU  the  cases  of  fever  came  from  the  country.  6th.  The 
fact  of  fever  not  often  spreading  in  famihes  in  this  city  when  brought 
from  the  country,  proves  that  the  causes  which  acted  in  the  country 
were  such  as  I  have  assigned — "  entassement,'''  bad  ventilation,  filth,  &c. 

While  this  sheet  is  going  through  the  press,  we  have  had  another 
practical  proof  of  the  operation  of  the  causes  I  have  in  this  lecture  men- 
tioned, as  productive  of  typhus  fever  in  Ireland.  The  gaol  of  Galway 
was  crowded  with  prisoners  in  the  beginning  of  this  year  (1848),  forced 
indeed  to  receive  nearly  double  the  number  it  could  contain  with  due 
attention  to  the  health  of  its  inmates.  As  a  consequence,  fever  broke 
out  amongst  those  confined  there,  and  is  now  spreading  among  the  in- 
habitants of  the  town.     This  fact  needs  no  comment ! 


100 


LECTURE  VIII. 


GENEEAL   OBSERVATIONS    ON    FEVER. CLASSIFICATION. —  CONTAGION. 


I  have  abeady  stated  that  when  a  person  gets  a  feverish  cold  in  Ireland, 
it  is  more  apt  to  pass  into  continued  fever  than  it  is  in  England :  this 
is  especially  the  case  when  fever  prevails  as  an  epidemic,  in  which  case 
the  transition  into  fever  takes  place  on  account  of  one  or  other  of  the 
following  causes.  Eirst — the  patient  had  been  exposed  to  contagion, 
whose  effects  might  never  have  become  perceptible,  had  not  his  consti- 
tution been  assailed  by  the  feverish  cold.  Secondly — in  many  cases 
there  has  been  no  previous  exposure  to  contagion,  and  yet  a  feverish 
cold  will  finally  determine  the  breaking  out  of  fever,  no  doubt  under  the 
action  of  the  prevailing  epidemic  influence.  Tliirdly — individuals  who 
are  debiHtated  by  excesses,  night  watching,  and  bodily  fatigue,  are  of  all 
others  the  most  liable  to  slide  from  feverish  cold  into  fever  :  if  in  addi- 
tion to  these  causes,  mental  anxiety,  or  intellectual  labour  have  been 
harassing  the  individual,  the  fever  generally  assumes  a  most  dangerous 
form,  being  attended  with  want  of  sleep,  raving,  and  often  violent  deli- 
rium early  in  the  disease. 

The  well  known  fact  that  individuals  have  sickened  on  the  spot  on 
smelling  the  effluvia  from  a  patient's  person  or  evacuations,  has  led  to 
the  supposition  that  the  contagion  of  fever  influences  the  system  tlirough 
the  nerves ;  and  in  support  of  this  opinion  many  refer  to  Prussic  acid, 
which,  they  say,  kills  by  its  action  on  the  nerves,  and  before  it  has  been 
absorbed. 

Another  class  of  inquirers  asserts  that  the  blood  is  the  seat  of  the  first 
morbid  change,  and  with  equal  confidence  refers  to  the  action  of  vegetable 
poisons,  which  they  assert  never  produce  any  effect  on  the  system,  until 
they  enter  the  circulation.^  In  the  present  state  of  our  knowledge  it  is 
quite  impossible  to  determine  in  what  manner  the  poison  acts,  and, 

♦  Blake's  Experiments,  Edinburgh  Med.  and  Surg.  Journal,  vol.  liii.p.  49.    And 
Miiller's  Elements  of  Physiology,  by  Baly,  2nd  edition,  vol.  i.  p.  262. 


THEORY    OF    FEVER.  101 

happily,  it  is  equally  unimportant.  This  much  is  certain,  that  changes 
in  the  nature  of  the  secretions,  as  in  the  sweat,  sputa,  mucus  of  the 
tongue,  feces  and  urine,  take  place  simultaneously  with  changes  in  the 
blood,  and  they  are  all  the  result  of  some  common  unknown  cause.  Of 
course  once  the  blood  is  changed,  the  secretions  become  more  rapidly 
altered,  and  wlien  the  secretions  are  changed,  the  blood  is  more  quickly 
deteriorated ;  but  the  knowledge  we  thus  obtain  leads  to  no  satisfactory 
explanation  or  practical  result. 

Lately  tlie  investigations  of  chemists  respecting  the  composition  of 
the  blood  in  fever  and  other  diseases,  have  excited  hopes  that  we  are  on 
the  eve  of  discovering  some  more  secure  basis  for  our  practice,  founded 
on  the  analysis  of  that  fluid.  I  must  confess,  that  however  I  applaud 
these  efforts  of  science,  I  entertain  no  hopes  that  they  will  be  followed 
by  the  expected  beneficial  consequences  :  for,  except  the  good  effected 
in  diabetes  mellitus,  by  diminishing  the  quantity  of  starch  in  the  bread 
such  patients  eat ;  and  the  advantage  derived  from  medicines  and  arti- 
cles of  diet,  in  certain  derangements  of  the  urinary  functions,  such  as  in 
the  phosphatic  and  lithic  diatheses ; — except  in  these  instances,  I  know 
of  no  improvement  in  practice  for  which  we  are  indebted  to  chemistry  : 
and  even  here  the  result  w  as  obtained  not  by  an  examination  of  living, 
but  of  secreted  fluids ;  and,  in  truth,  it  is  vain  to  look  for  remedies 
founded  on  chemical  principles,  when  these  principles  cannot  even  ap- 
proximate to  aftbrding  us  an  explanation  of  the  mode  of  action  of  our 
best  established  medicines.  When  chemistry  reveals  why  tartar  emetic 
vomits,  jalap  purges,  or  opium  causes  sleep — when  chemistry  detects 
palpable  changes  in  the  blood  produced  by  these  remedies,  then  we  may 
begin  to  hope  that  this  science  can  conduct  us  still  further,  and  may 
even,  by  disclosing  the  morbid  changes  which  the  blood  undergoes  in 
disease,  become  useful  to  us  in  searching  for  remedies  capable  of 
counteracting  and  even  preventing  these  changes. 

The  different  theories  of  fever,  as  they  have  been  called,  have  much 
and  often  injuriously  affected  practice.  The  speculations  of  Brown, 
Cullen,  Clutterbuck,  Broussais,  Rasori,  Armstrong,  and  our  Indian 
Physicians,  have  successively  introduced  the  stimulant,  diaphoretic,  ge- 
neral antiphlogistic,  leeching,  tartar  emetic,  mercurial  plans ;  each  of 
which  has  in  its  turn  been  pushed  to  a  most  deleterious  excess.  Por  my 
own  part,  I  have  long  abandoned  every  hope  of  being  able  to  frame  any 
satisfactory  theory  of  fever,  and  therefore  confine  myself  altogether  to  a 
diligent  study  of  its  symptoms,  watching  how  they  are  grouped,  and  in 
what  order  they  follow  each  other,  and  observing  closely  the  effects  of 
treatment  on  their  progress  ;  and  in  my  choice  of  remedies  I  am  guided 
either  by  experience,  or  an  analogy  derived  from  the  action  of  medicines, 


- 


10*2  CLINICAL  MEDICINE. 

in  other  diseases  which  present  the  greatest  similarity  to  the  complica- 
tions that  occur  in  fever. 

Fever  in  this  island  exhibits  a  great  variety  of  character,  and  even 
during  the  same  epidemic  remarkable  differences  are  observable,  as  ap- 
pears from  the  subjoined  summary,  taken  from  Cheyne  and  Barker's 
valuable  account  of  the  epidemic  fever  of  1817  and  1818 — vol.  i. 
p.  425  :— 

"  Delirium  ferox  was  observed  in  Limerick,  and  another  symptom 
indicating  a  determination  of  blood  to  the  head,  namely,  hemorrhage 
from  the  nose,  which,  in  some  instances,  took  place  to  a  very  consider- 
able extent. 

"As  to  the  organs  chiefly  affected  in  the  progress  of  the  disease, 
some  variety  seemed  to  exist.  In  most  instances  the  brain  has  been  re- 
ported as  the  organ  which  suffered  chiefly.  In  some  places,  as  at  Eiinis, 
the  lungs  were  not  all  affected,  during  the  early  periods  of  this  epidemic 
fever ;  but  in  other  places  the  lungs  next  to  the  brain  principally  suf- 
fered ;  this  was  observed  in  Listowel.  The  same  remark  was  made  at 
Tralee,  and  Dr.  Bishop  observed  at  Kinsale,  that  the  lungs  were  fre- 
quently affected  in  children.  At  Ennis  it  was  noticed  as  a  peculiarity 
in  the  fever,  that  profuse  perspiration  occurred  in  its  earlier  stages  with- 
out any  relief  to  the  patient ;  and  it  was  remarked  at  Waterford,  as 
stated  in  the  report  at  page  251,  that  copious  perspiration  often  afforded 
no  rehef.  Yellowness  of  the  skin  and  tunica  adnata  of  the  eyes,  was 
frequently  noticed  at  Cork.  The  head  and  bihary  system  were  more 
than  usually  affected. 

"  As  the  disease  advanced,  it  was  observed  in  most  or  ah.  parts  of  the 
province,  that  eruptions  of  different  kinds,  either  closely  aUied  to,  or 
varieties  of,  those  termed  petechial,  very  generally  accompanied  it.  In 
some  instances  the  eruption  was  papular,  or  a  motley  appearance  of  the 
skin,  or  a  rash  somewhat  resembling  the  measles  showed  itself.  At 
Cork,  Dr.  M.  Barry  remarked  that  in  the  species  of  fever  which  he 
termed  s}Tiochus,  petechise  seldom  occurred  earlier  than  the  fourth  or 
fifth  day ;  but  his  observation,  if  it  does  not  express  it  du'ectly,  at  least 
implies  that  their  occurrence  was  frequent.  They  were  generally  of  a 
hright  red  colour,  sometimes  small,  at  other  times  large.  He  did  not 
consider  them  dangerous,  nor  find  it  necessary  to  abstain  from  those 
measures  of  depletion  which  were  useful  when  high  excitement  prevailed. 
In  a  communication  from  Clonmel,  Dr.  Eitzgerald  states,  that  petechiee 
occurred  in  four  cases  out  of  five.  At  Eermoy,  petechise  appeared  very 
generally  among  tlie  poor.  At  Kinsale,  a  red  rash,  we  believe  of  the 
kind  above  mentioned  as  resembling  that  of  the  measles,  was  common, 
and  petechise  were  more  inclined  to  be  red  than  brown  in  tliat  neigh- 


THEORY    OF    FEVER.  103 

bourliood.  At  Listowel,  petecliiae  were  so  common,  that  Dr.  O'Cou- 
nel  did  not  see  six  cases  of  fever  unattended  by  a  petechial  eruption, 
which  often  appeared  early  in  the  disease.  The  frequency  of  petechiee 
was  noticed  also  at  Waterford,  as  well  as  of  the  eruption  resembling 
measles  already  mentioned.  The  frequency  of  an  eruption  resembling 
measles  was  noticed  at  Bandon  by  Dr.  Clarke  and  Dr.  Jenkins.  At 
Clonmel  petecliise  were  common  even  amongst  children,  in  whose  cases 
this  eruption  was  not  indicative  of  peculiar  danger,  but  on  the  contrary, 
often  attended  a  mild  disease.  It  was  observed  in  the  neighbourhood 
of  Tramore,  and  we  believe  the  same  to  have  happened  in  every  part  of 
Ireland,  that  one  member  of  a  family  had  petechise  and  aggi'avated 
symptoms  of  typhus,  whilst  the  relatives  in  the  same  room  had  fever  in 
the  mildest  form.  In  many  instances,  particularly  in  the  more  advan- 
ced stages  of  the  epidemic,  the  lungs  were  observed  to  suffer,  as  at 
Eermoy,  Listowel,  and  Mallow,  according  to  the  authorities  already 
quoted ;  but  both  at  Cork  and  at  Eimis,  places  very  remote  from  each 
other  in  this  province,  the  lungs  at  least  at  the  commencement  of  its 
epidemic  progress,  were  but  rarely  affected  in  this  fever. 

"As  the  epidemic  advanced,  gastric  symptoms  were  observed,  and 
mention  has  been  already  made  of  the  frequency  at  this  time  of  dysen- 
tery, which,  in  many  parts  of  Munster,  kept  pace  with  fever.  Dr  Gro- 
gan,  of  Limerick,  remarked,  that  pains  resembling  those  of  rheumatism 
were  common ;  and  he  also  noticed  a  symptom,  which  there  is  reason  to 
believe  was  not  unfrequent  in  most  parts  of  Ireland,  namely,  that  the 
tongue,  which  in  most  febrile  diseases  is  white  or  altered  in  colour  and 
other  appearances,  in  many  cases  exhibited  no  morbid  change,  and  re- 
mained moist  and  clean  during  a  great  part  of  the  disease.  Prom  the 
same  authority  we  learn  that  increased  heat  of  the  surface,  which  is  ge- 
nerally considered  pecuKarly  characteristic  of  fever,  was,  in  many  in- 
stances at  Limerick,  altogether  wanting;  this  absence  of  the  usual 
febrile  lieat  is  observed  in  the  worst  kinds  of  fever.^"* 

Tarther  on,  the  report  states  that,  "  Dr.  Milner  Barry,  of  Cork,  iu 
his  account  of  the  fever  iu  that  city,  relates  that  the  disease  presented 
itself  under  different  forms,  which  he  arranges  under  the  following 
heads: — 1.  Synochus;  2.  S.  Cephalica;  3.  S.  Puknonica;  4.  S.  He- 
patica;  5.  S.  Gastrica;  6.  S.  Enterica;  7.  Typhus  gravior ;  8.  Ty- 
phus Mitior;  9.  Pebricula.  Prom  the  arrangement  which  Dr.  Barry 
here  adopts,  it  is  evident  that  a  determination  to  particular  organs  was 
at  Cork,  as  at  other  places,  of  frequent  occurence.'''' 

Por  more  than  twenty  years  I  have  in  my  lectures  advocated  the 
doctrine,  that  morbid  anatomy  had  not  served  to  reveal  the  cause  of 
fever,  which  I  looked  upon  to  be  an  essential  disease,  or,  to  use  the 


104  CLINICAL   MEDICINE 

words  of  Fordyce,  "  Fever  is  a  disease  which  affects  the  whole  system  ; 
"  it  affects  the  head,  trunk,  and  extremities  ;  it  affects  the  circulation, 
"  absorption,  and  the  nervous  system  j  it  affects  the  body,  and  it  affects 
"  the  mind  ;  it  is  therefore  a  disease  of  the  whole  system,  in  ■  the  fullest 
^'  sense  of  the  term.  It  does  not,  however,  affect  the  various  parts  of 
'*  the  system  uniformly  and  equally,  but,  on  the  contrary,  sometimes  one 
''part  is  more  affected  than  another.''  "  This  excellent  view  of  fever 
seems  to  be  borne  out  completely  by  modern  pathology,  and  particularly, 
the  last  part,  where  he  says,  that  in  cases  of  fever  one  part  is  more 
affected  than  another.  We  have,  for  instance,  cerebral  fevers,  ner\^ous, 
bihous,  gastric,  and  catarrhal  fevers,  by  which  it  is  to  be  observed,  we 
do  not  mean  to  imply  that  there  is  nothing  more  than  simple  disease  of 
the  brain,  or  nerves,  or  liver,  or  bowels,  or  respiratory  system,  but  that 
in  each  of  these  fevers,  disease  predominates  in  some  particular  part. 
So  that  when  we  speak  of  these  fevers,  we  speak  of  such  a  fever  as 
Fordyce  has  described,  in  which  one  part  of  the  body  is  affected  more 
than  the  rest.""^ 

I  am  happy  to  find  that  the  views  I  have  so  long  entertained  in  oppo- 
sition to  the  great  majority  of  writers  both  in  Britain  and  on  the  Con- 
tinent, are  now  generally  acknowledged  to  be  correct,  as  will  appear  by 
the  following  passage  taken  from  the  able  essay  on  continued  fever  by 
Dr.  Cliristison  in  the  "  Library  of  Medicine.^' 

*'  Anatomical  characters  of  continued  fever. — The  pathological  ana- 
tomy of  continued  fever  remained,  till  lately,  in  a  very  crude  and  un- 
satisfactory condition.  But  no  other  topic  has  attracted  so  much 
attention  during  the  last  five  and  twenty  years,  or  has  been  investigated 
with  more  success,  so  far  as  the  accumulation  of  facts  goes.  Whether 
the  result  has  been  hitherto  beneficial  in  reference  either  to  pathologi- 
cal doctrine  or  medical  practice,  is  a  question  which  admits  of  some 
doubt.  A  very  great  variety  of  morbid  appearances  has  been  indicated 
as  occurring  in  fever.  Of  these  many  are  plainly  incidental,  because 
they  do  not  by  any  means  present  themselves  regularly.  Others,  how- 
ever, have  been  held  to  be  invariable ;  and  consequently  authors  have 
sought  for  the  nature  and  essence  of  fever,  in  the  local  morbid  action 
which  gives  rise  to  such  appearances.  On  taking  into  account  the  ge- 
neral result  of  the  observations  of  all  pathologists  of  credit,  it  seems 
impossible  to  avoid  the  conclusions,  that  no  morbid  appearance  is  in- 
variable except  congestion  of  internal  organs ;  that  every  other  patho- 
logical fact  which  has  been  observed  is  not  constant,  and  is  therefore 
the  effect  of  a  secondary  disease ;  and  that,   in   all   the   observations 

*  Stokes'  Practice  of  Physic^  American  Edition,  page  4011. 


CLASSIFICATION    OF    HUSH    FEVERS.  105 

hitherto  made  on  the  pathological  anatomy  of  fever,  we  must  be  content 
with  discovering  its  consequences^  not  its  causes.  The  information  wliich 
has  been  amassed  is  important  in  a  practical  point  of  view,  as  turning 
the  attention  of  practitioners  to  the  necessity  of  studying  and  treating 
those  secondary  affections,  wdiich  in  various  circumstances  are  the  oc- 
casion of  suffering,  danger  or  death.  But  it  does  not  seem  to  throw 
much  light  on  the  real  essence  of  fever ;  and  by  being  rashly  assumed 
to  furnish  that  light,  it  has  led  to  grave,  theoretical,  and  practical 
errors/'^ 

In  fact,  gentlemen,  the  knowledge  we  possess  of  the  pathology  of 
typhus  fever,  is  of  a  negative  character.  Pathology  teaches  us  what 
typhus  is  not  J  rather  than  what  it  is  ;  it  shows  us  that  it  is  neither  cere- 
britis,  meningitis,  pneumonia,  pleurisy,  gastritis,  or  enteritis,  for  it  may 
exist  without  any  of  these,  and  they  may  exist  without  typhus  fever ; 
but  it  also  show^s  that  one  or  other  of  these  lesions  frequently  arises  in 
the  course  of  that  fever,  and  these  require  special  attention. 

It  is  difficult  to  classify  the  different  varieties  of  fever  that  are  ob- 
served in  this  city.  The  following  are  the  most  remarkable  of  the  dis- 
tinct varieties  that  have  come  under  my  notice  : — 

1st,  Simple  continued  fever,  without  maculae,  or  any  notable  deter- 
mination to  particular  organs.  2nd,  Continued  fever,  without  maculae, 
with  determination  to  some  organ.  3rd,  Continued  fever,  with  maculae. 
4th,  Continued  fever,  accompanied  j^-o?^  the  very  beginning  by  gastric 
derangement  and  epigastric  tenderness.  5th,  The  last  mentioned 
species,  but  in  a  more  intense  form,  having  black  vomit  and  yellowness 
of  the  skin  superadded.     6th,  Continued  fever,  with  petechiae. 

I  have  observed  each  of  these  varieties  of  fever  constituting  epide- 
mics, which  lasted  for  longer  or  shorter  periods  :  but  with  us  the  domi- 
nant type  of  epidemics  is  the  maculated  form.  This  species,  too,  con- 
fers, more  immunity  upon  the  sufferers  than  any  other  variety  of  fever, 
and  in  this  respect,  as  well  as  in  its  well  marked  eruption,  it  approaches 
in  character  to  the  exanthemata :  like  the  exanthemata,  too,  this  species 
of  fever  seems  to  be  the  most  contagious. 

Concerning  contagion,  the  physicians  of  Ireland  and  Scotland  are 
nearly  agreed  in  attributing  that  quality  to  fever.  The  fever  w^ards  of 
the  Meath  Hospital  are  by  no  means  crowded,  and  are  both  well  venti- 
lated and  cleanly,  while  the  building  itself  is  placed  in  the  most  salu- 
brious part  of  the  vicinity  of  Dublin,  being  built  upon  the  site  of  Dean 
Swift's  garden ;  and  yet  it  almost  invariably  happens,  that  when  a 
patient,  labouring  under  any  other  acute,  or  any  chronic  disease,  is 

*  Library  of  Medicine,  Vol.  i.  p.  10/j. 


106  CLINICAL    MEDICINE. 

admitted  into  a  fever  ward,  he  gets  fever  in  the  course  of  a  fortnight, 
or  even  sooner.  This  happens  the  more  surely  if  the  patient  is  placed 
in  the  immediate  vicinity  of  a  maculated  case.  Among  the  pupils  who 
attend  the  hospital,  the  greater  number  are  sooner  or  later  attacked  by 
fever ;  and  the  same  is  true  of  the  porters,  laundry  maids,  and  nurses. 
Moreover,  in  the  recent  epidemic  with  wliich  this  country  was 
afflicted,  the  contagious  character  of  the  fever,  was,  as  I  have  al- 
ready shown,  peculiarly  manifested ;  and  especially  by  the  great  mor- 
tality which  it  caused  among  the  members  of  the  medical  profession."^ 

I  have  great  pleasure  in  recommending  Dr.  Christison^s  observations 
on  this  subject,  and  shall  here  quote  briefly  some  of  the  arguments 
advanced  by  him  in  support  of  the  contagious  nature  of  the  disease. 
In  the  first  place  he  says,  that  in  districts  thinly  inhabited,  fever  is 
generally  very  rare,  whereas  in  large  towns,  where  numbers  of  people 
are  living  in  a  crowded  state,  typhus  fever  is  never  absent.  When  it 
becomes  epidemic  in  a  large  town,  it  never  bursts  forth  with  impetu- 
osity, like  the  diseases  of  midouhted  miasmatic  origin ;  but  extends 
gradually,  and  always  the  more  slowly  the  larger  the  city,  so  that  many 
months  may  elapse  before  it  reaches  its  full  height.  It  then  begins  to 
decline,  retires  as  gradually  as  it  commenced,  and  finally  resumes  its 
natural  condition,  affecting  only  a  few  individuals  here  and  there,  and 
at  distant  intervals. 

At  the  commencement  of  an  epidemic,  fever  is  found  to  spread  at 
first,  not  by  scattered  unconnected  cases  occurring  at  a  distance  from 
one  another,  but  by  slow  degrees  around  one  or  more  invaded  localities 
as  foci  j  first  creeping  from  one  individual  to  another  of  a  family,  then 
from  family  to  family — according  to  their  proximity,  relationship,  or 
general  intercourse,  and  at  length  to  the  surrounding  population  pro- 
miscuously. 

But  a  further  argument  of  very  great  weight  may  be  drawn  even 
from  the  very  violations  of  this  general  rule.  Eor  sometimes  the  dis- 
ease is  seen  suddenly  to  arise,  and  gradually  to  spread  in  parts  of  a 
town  where  it  had  not  previously  existed ;  and  this  in  concurrence  with 
the  arrival  of  the  disease  by  importation  from  a  previously  invaded 
locality. 

'^  Another  argument,  more  powerful  perhaps  than  any  other,  and 
upon  which  alone  the  doctrine  of  the  coymmmicahility  (Dr.  Christison 
used  this  word  in  preference  to  contagion  or  infection),  of  fever  might 
be  rested,  is,  that  in  circumscribed  localities,  inhabited  by  crowded 

*  For  much  most  valuable  information  on  this  head,  I  would  refer  to  Drs.  Cusack  and 
Stokes'  laborious  and  trustworthy  essay,  in  the  fifth  volume  of  the  Dublin  Quarterly 
Journal  of  3Iedical  Science,  new  series. 


COMMUJSICABILITY    OF    FEVEll.  107 

bodies  of  men,  fever  is  observed  invariably  to  spread  among  the  healthy, 
when  it  is  introduced  to  a  great  extent  from  without,  but  never  mate- 
rially at  any  other  time.  This  is  a  general  mode  of  expressing  the 
history  of  such  institutions  as  infirmaries  and  fever  hospitals.  During 
the  last  twenty  years  the  Infirmary  of  Edinburgh  has  been  made  the 
receptacle  of  a  large  proportion  of  fever  cases  in  three  epidemics,  which 
have  lasted  between  three  and  four  years ;  and  there  have  been  two 
intervals  varying  from  three  to  five  years  in  duration.  During  the 
intervals,  when  fever  cases  from  without  were  few,  fevers  originating 
within  the  hospital  were  extremely  rare  among  any  classes  of  individuals 
attached  to  its  service.  But  during  the  prevalence  of  the  several 
epidemics,  fever  abounded  in  every  department  of  its  service  :  physicians, 
clinical  clerks,  general  servants,  nurses,  washerwomen,  apothecary's 
assistants,  all  suffered  more  or  less,  and  some  to  an  excessive  degree. 
The  same  facts  were  observed  even  more  remarkably  in  an  institution 
w^hich  was,  during  the  same  interval,  occasionally  occupied  as  a  fever 
hospital.  In  three  epidemics  it  was  made  use  of  for  this  purpose ;  and 
at  various  periods  during  the  last  twenty-five  years,  it  has  also  been 
occupied,  when  fever  did  not  prevail  epidemically  in  the  city,  by  crowded 
bodies  of  men,  first  by  soldiers  as  a  barrack,  then  as  a  retreat  for  some 
hundreds  of  poor  people  who  were  turned  out  of  their  houses  in  winter 
by  an  extensive  fire,  next  as  a  quarantine  house  during  the  prevalence 
of  cholera,  and  for  some  years  past,  during  the  worst  epidemic  of  fever 
which  has  yet  prevailed  in  the  city,  it  has  been  occupied  by  about  300 
of  the  very  lowest  of  the  community,  namely,  as  a  house  of  refuge  for 
vagrants  and  other  destitute  persons.  Now,  on  each  occasion,  when  it 
was  occupied  as  a  fever  hospital,  the  people  on  service  in  the  institution 
suffered  to  an  extraordinary  degree,  scarcely  a  single  individual  escaping 
an  attack,  who  remained  a  moderate  length  of  time  in  it.  But  on 
other  occasions,  fever  was  either  absolutely  unknown,  or  the  cases  were 
rare  and  distant,  and  easily  referrible  to  the  particular  manner  of  life 
of  the  individuals  composing  the  population  of  the  establishment.  It 
is  also  worthy  of  notice,  in  reference  to  both  chains  of  facts  here  men- 
tioned, that  neither  around  the  infirmary,  nor  around  the  late  fever 
hospital,  did  fever  ever  prevail  to  any  material  extent  during  any  of  its 
epidemic  visitation s.^"*"^ 

It  is  unnecessary  to  allude  to  the  many  instances  of  fever  occui-ring 
amongst  nurses,  porters,  and  clinical  clerks  in  difierent  fever  hospitals, 
facts  which  strongly  bear  out  the  view  that  typhus  fever  is  eminently 
contagious. 

*  Library  of  Medicine,  Vol.  i.  p.  156. 


108  CLINICAL   MEDICINE. 

Another  interesting  point  connected  with  the  contagion  of  fever  has 
lately  been  inquired  into,  viz.  to  determine  the  particular  period  of  the 
disease  when  this  character  is  most  remarkable. 

Dr.  Perry,  of  Glasgow,  was  the  first,  I  beHeve,  who  advanced  the 
opinion  that  the  stage  of  convalescence  was  the  most  infectious  in 
typhus  fever.  He  considers  typhus  fever  as  a  true  exanthema.  He 
says,  ''  I  have  for  some  years  entertained  the  opinion,  founded  upon  an 
extensive  series  of  observations,  that  contagious  typhus  is  an  exanthe- 
matous  disease,  and  is  subject  to  all  the  laws  of  the  other  exanthemata ; 
that,  as  a  general  rule,  it  is  only  taken  once  in  a  life  time,  and  that  a 
second  attack  of  typhus  does  not  occur  more  frequently  than  a  second 
attack  of  small  pox,  and  judging  from  my  own  experience,  less  fre- 
quently than  a  second  attack  of  measles  or  scarlet  fever. 

'^  From  numerous  observations  and  experiments  I  am  satisfied,  that 
it  is  not  contagious  before  the  ninth  day,  perhaps  not  till  a  later  period 
of  the  disease.  Among  many  circumstances  which  establish  this 
opinion,  I  may  mention  one  experiment  which  I  made  upon  a  pretty 
extensive  scale.  The  fever  wards  of  the  Glasgow  Royal  Infirmary  are 
each  capable  of  containing  twenty  patients.  The  beds  are  arranged  in 
two  opposite  rows,  and  are  pretty  near  each  other.  While  the  patients 
are  in  the  acute  wards,  they  are  not  allowed  the  use  of  their  clothes, 
though  they  may  be  able  to  sit  up ;  they  are,  therefore,  almost  con- 
stantly confined  to  bed,  excepting  when  rising  to  stool ;  and  there  is 
about  one  close-stool  to  every  tlu-ee  patients.  Into  the  fever-house  are 
admitted  cases  of  measles,  scarlet  fever,  and  small  pox ;  and  patients 
are  very  frequently  sent  in  labouring  under  bronchitis,  pneumonia, 
erysipelas,  and  other  local  inflammatory  affections.  I  found  by  expe- 
rience, that  when  the  latter  class  of  patients  was  sent  to  the  convales- 
cent ward,  where  they  necessarily  mixed  with  the  others,  almost  all 
those  who  had  not  a  previous  attack  of  typhus  fever,  were  either  seized 
with  it  before  leaving  the  house,  or  returned  soon  after  their  dismissal 
labouring  under  it ;  the  period  intervening  between  the  time  of  their 
being  sent  to  the  convalescent  ward,  and  the  attack,  never  being  less 
than  eight  days.  Although  means  were  taken  to  keep  those  recovering 
from  small  pox,  scarlatina,  &c.,  in  a  separate  room  from  those  convales- 
cent from  typhus,  the  rooms  being  adjoining  the  non-intercourse  was 
incomplete,  and  the  result  was,  that  these  diseases  occasionally  spread 
among  the  typhus  convalescents,  and  the  convalescents  from  small-pox 
and  scarlatina  caught  typhus.  In  consequence  of  these  observations,  I 
adopted  the  practice  of  not  sending,  as  formerly,  to  the  convalescent 
wards,  those  patients  afi'ected  with  inflammatory  diseases,  unless  I  as- 
certained tliat  they  were  secured  against  the  disease  bv  having  had  a 


PETECIIJ.VL    FEVEK.  109 

previous  attack  of  typhus ;  but  kept  tliem  in  the  acute  fever  wards  till 
they  were  so  far  recovered  as  to  go  to  their  own  house,  and  the  result 
was  (and  the  practice  was  continued  for  several  months),  that  not  one 
of  those  detained  in  the  acute  wards  caught  the  disease  while  there,  or 
returned  with  it  afterwards.  From  the  above  and  other  observations,  I 
have  adopted  the  opinion,  that  typhus,  like  measles,  small-pox,  &c.,  is 
chiefly  spread  during  the  period  of  convalescence.  In  the  paper  already 
noticed,  I  have  mentioned  the  desquamation  of  the  cuticle,  which 
usually  takes  place  when  a  patient  is  convalescent  from  typhus.  Do 
the  fine  scales  thrown  off  in  this  state  contain  the  poison  which,  by 
adhering  to  the  clothes  and  hair  of  the  patient,  are  carried  about  with 
him,  and  being  rubbed  off  are,  while  floating  in  the  atmosphere,  ap- 
plied to  the  mucous  surface,  or  inhaled  by  a  susceptible  recipient,  in 
whom  it  produces,  after  a  certain  time,  the  specific  disease  ?^^^ 

I  must  here  acknowledge,  although  frequent  mention  has  been  made 
in  this  lecture  of  petechial  fevers,  particularly  in  the  passage  cited  from 
Cheyne  and  Barker's  work  respecting  the  fever  of  1817  and  1818,  and 
although,  in  compliance  with  the  generally  received  opinions,  I  have 
set  down  this  fever  as  a  distinct  species,  that  I  myself  have  never  seen 
petechial  fever  epidemic  in  Ireland.  I  was  clinical  clerk  at  Sir  Patrick 
Dun's  Hospital  during  the  gi-eat  epidemic  of  1816  and  1817.  The 
eruption  consisted  of  maculae,  somewhat  resembling  measles,  frequently 
dark  and  livid  in  bad  cases ;  but  except  in  a  very  few  instances  indeed 
there  were  no  true  petechise.  In  1822  I  had  the  charge  of  a  large 
district  in  the  town  of  Galway,  when  fever  was  committing  great  ravages  j 
then,  too,  the  eruption  was  maculated.  I  cannot  account  for  so  many 
witnesses  testifying  the  contrary  to  this  statement,  except  by  supposing 
them  to  have  been  misled  by  appearances ;  for  it  must  be  confessed, 
that  although  true  petechia  are  rare,  true  fiea-hites  are  common  in 
Ireland.  Most  observers,  too,  seem  to  have  been  very  inaccurate  in 
their  pliraseology,  as  is  evident  from  the  above  quotation  from  Cheyne's 
work.  Dr.  Barry  plainly  uses  the  word  petechia  very  loosely — "  Thei/ 
were  generally/  of  a  bright  red  colour,  sometimes  small,  at  other  times 
large"  Surely  this  is  quite  descriptive  of  maculse,  but  totally  inap- 
plicable to  petechise ;  and  the  same  may  be  said  of  the  other  observers, 
most  of  whom,  I  verily  believe,  overlooked  the  true  eruption,  and  noted 
down  flea-bites  as  petechise  !  Connected  with  the  question  first  raised 
by  Dr.  Perry,  whether  maculated  typhus  should  be  considered  as  an 
exanthema,  the  fact  is  deserving  of  notice,  that  children  exhibit  the 

*  Dublin  Medical  Journal,  Vol.  x.  p.  385. 


110  CLINICAL   MEDICINE. 

eruption  much  less  frequently  than  adults,  although  they  are  quite  as 
liable  to  the  fever,  when  it  is  epidemic.  This  fact  is  the  more  remarka- 
ble, because  in  measles,  scarlatina,  &c. — the  true  exanthemata,  the 
eruption  is  more  constant  in  children  than  in  adults. 


Ill 


LECTURE  IX. 


THE  GENERAL  TREATMENT  OP  FEVER. 


I  SHALL  to  day  proceed  to  speak  of  the  general  treatment  of  fever ; 
and  in  the  first  place  I  may  observe,  that  we  are  now  at  a  point  of  time 
possessing  no  common  interest  for  the  reflection  of  medical  observers.^ 
It  is  nearly  two  years  since  my  attention  was  first  arrested  by  the  ap- 
pearance of  maculated  fever,  of  which  the  first  examples  were  observed 
in  some  hospital  patients  from  the  neighbourhood  of  Kingstown.     This 
form  of  fever  has  lasted  ever  since,  prevailing  universally,  as  if  it  had 
banished  all  other  forms  of  fever,  and  being  almost  the  only  type  no- 
ticed in  our  wards.     Within  the  last  four  days,  however,  a  change 
appears  to  have  taken  place.     Scarcely  any  cases  of  maculated  fever 
have  been  admitted  within  the  last  fortnight,  and  the  majority  of  fever 
patients  at  present  under  treatment  are  free  from  cutaneous  eruption  so 
frequently  observed  during  the  last  two  years.     The  cases  which  we 
have  recently  admitted  present  no  spots,  or  maculse,  and  have  been 
termed,  perhaps,  improperly,  simple  typhoid  fever.     And  here  permit 
me  to  observe,  that  it  would  be  very  wrong  to  conclude,  from  this  cir- 
cumstance, that  our  recent  cases  are  of  a  more  favourable  description 
than  those  which  preceded  them ;  the  disease,  it  is  true,  appears  to 
have  lost  a  character  which  is  always  looked  upon  as  bad  and  unfavour- 
able, but  it  may  be  just  as  dangerous  a  modification  of  fever  as  the 
eruptive  typhus.     During  the  predominance  of  the  latter  form,  all  cases 
without  maculse  were  in  general  simple  and  free  from  danger ;  but  it  is 
probable  that  this  is  not  the  case  at  present.     There  are  two  cases  of 
this  non-maculated  typhus  in  the  female  ward,  which  are  of  an  extremely 
doubtful  character,  and  in  which  it  would  be  difficult  to  predict  the 
result.     Indeed,  were  I  to  make  any  prognosis,  I  should  say  that  the 
chances,  if  not  against  them,  are  at  least  very  fairly  balanced. 

»  The  beginning  of  this  Lecture  was  delivered  during  the  session,  1836-7. 


112  CLINICAL   MEDICINE. 

Now,  gentlemen,  as  it  appears  we  have  come  to  a  change,  and  that 
we  may  have  to  treat  a  new  modification  of  fever,  it  behoves  us  to  be 
extremely  vigilant.     I  invite  you  to  watch  and  study,  with  the  closest 
attention,  the  cases  of  fever  which  come  before  you.     Let  us,  in  the 
first  place,  endeavour  to  ascertain  whether  we  have  seen  the  close  of 
one  epidemic,  and  are  now  at  the  commencement  of  another.     The 
number  of  cases  of  simple  typhoid  fever  has,  you  perceive,  increased  in  a 
very  remarkable  manner,  and  the  number  of  cases  of  eruptive  typhus 
has  become  remarkably  scarce.     But  there  is  another  and  a  more  im- 
portant reason  why  we  should  study  these  cases  with  all  due  diligence 
and  attention.     They  may  be  the  first  examples  of  a  new  epidemic,  and 
every  new  epidemic,  as  it  has  its  peculiar  characters,  so  has  it  its  pecu- 
liar treatment.     We  cannot  follow  the  same  track  which  we  have  pur- 
sued for  the  last  two  years — we  cannot  apply  our  remedies  with  the 
confidence  of  experience — ^^e  must  now  strike  into  a  new  path,  and 
for  some  time  our  practice  must  be  tentative  and  experimental.     It  was 
only  after  a  good  deal  of  experimental  observation  that  we  were  able  to 
arrive  at  a  plan  of  treatment  adapted  to  meet  the  exigencies  of  the  ma- 
culated form  of  fever  :  and  it  is  very  probable  that  this  new  fever  may 
prove  at  first  extremely  difficult  to  manage ;  and  it  may  be  some  time 
before  the  diminished  rate  of  mortality  shaU  show  that  we  have  at  length 
discovered  its  true  character,  and  the  remedies  best  calculated  to  arrest 
its  progress. 

Let  me  now  direct  your  attention  to  some  practical  points  con- 
nected with  the  treatment  of  the  maculated  fever  which  has  prevailed 
for  the  last  two  years,  and  which  has  spread  to  a  very  considerable  ex- 
tent in  this  city  and  its  environs,  attacking  alike  the  upper,  middle,  and 
lower  classes  of  society.  It  is  not  my  intention  to  enter  into  a  detailed 
history  of  the  origin  and  progress  of  this  fever,  its  varieties,  symptoms, 
and  pathological  phenomena ;  my  purpose  is  to  furnish  you  with  a  brief 
but  comprehensive  outline  of  its  treatment,  and  of  the  remedies  which 
have  been  found  most  successful  in  its  removal,  as  well  as  the  most 
appropriate  time  and  mode  for  their  application. 

Having  made  these  general  observations,  I  may  observe,  in  addition, 
that  in  the  whole  range  of  human  maladies  there  is  no  disease  of  such 
surpassing  interest  and  importance  as  fever ;  and  I  cannot  dwell  too 
much  on  the  necessity  of  your  applying  most  attentively  to  the  study 
of  its  pathology  and  treatment.  If  you  compare  the  mortality  from 
fever  with  that  resulting  from  any  other  disease  in  this  country,  you  will 
be  struck  with  the  overwhelming  fatality  of  this  aff'ection,  and  will  readily 
admit  the  inestimable  value  of  a  thorough  knowledge  of  its  nature  and 
treatment.     Eecollect,  too,  that  fever  is  a  disease  which  numbers  among 


THE  GENERAL  TREATMENT  OF  FEVER.  113 

its  victims  persons  chiefly  in  the  prime  of  life,  and  during  the  most 
active  and  useful  stage  of  existence, — ^fathers  and  mothers,  persons  who 
are  the  ornament,  or  the  stay  and  support  of  their  families,  the  intel- 
lectual, the  industrious,  the  efficient, — those  whose  lives  are  most  valu- 
able to  their  friends  and  to  society.  Tliis  gives  an  additional  interest  to 
the  study  of  fever,  and  should  stimulate  you  to  endeavour  to  arrive  at  a 
correct  knowledge  of  its  nature  and  treatment. 

And  here  let  me  observe,  that  there  is  nothing  more  untrue  than  the 
assertion,  that  the  treatment  of  fever  is  a  matter  of  indifference.  It  has 
been  the  custom  to  look  upon  every  plan  of  treating  fever  as  idle  and 
absurd,  and  until  very  lately  there  were  many  persons  in  this  country  who 
believed  that  patients  recovered  not  from  having  had  the  advantage  of 
treatment,  but  from  goodness  of  constitution  or  some  favourable  ac- 
cident ;  and  it  was  usual  with  such  persons  to  appeal  to  the  experience 
of  Dr.  Eutty,  who  in  recording  the  history  of  the  epidemics  of  his  own 
time  (1741),  observes  ^^the  poor,  abandoned  to  the  use  of  whey  and 
God's  good  providence  recovered,  while  those  who  had  generous  cor- 
dials and  great  plenty  of  sack,  perished.''^  And,  indeed,  I  must  admit 
that  the  treatment  of  some  of  the  cases  of  fever  which  I  witnessed  when 
a  student,  would  seem  to  justify  the  quaint  and  sarcastic  observation  of 
Dr.  Rutty.  At  that  period,  whether  it  was  from  bad  treatment,  or 
from  what  has  been  termed  the  nimia  diligentia  medici,  it  is  a  fact  that 
the  maximum  of  mortality  was  among  the  rich,  and  that  those  who 
were  most  attended  to,  died  most  speedily.  In  the  epidemics  of  1816, 
1817,  1818,  and  1819,  it  was  found  by  accurate  computation,  that  the 
rate  of  mortality  was  much  higher  among  the  rich  than  among  the 
poor."^  This  was  a  startHng  fact,  and  a  thousand  different  explanations 
of  it  were  given  at  the  time ;  but  I  am  inclined  to  think  that  the  true 
explanation  was,  that  the  poor  did  not  get  so  much  medicine,  and  that 
in  them  the  vis  medicatrix  had  more  fair  play.t  I  could  appeal  to  tlie 
practice  of  those  times  in  proof  of  this  opinion,  and  as  we  go  along  I 
shall  have  an  opportunity  of  alluding  to  this  part  of  the  subject  again, 
and  contrasting  the  practice  of  the  present  day  with  that  which  was  ge- 

*  "  The  rich  are  less  frequently  affected  with  epidemic  fevers  than  the  poor,  but  more 
frequently  die  of  them.  Good  fare  keeps  off  diseases,  but  increases  their  mortality  when 
they  take  place." — Fletcher^s  Pathology,  p.  27. 

f  "  On  the  whole  the  mildest  and  simplest  treatment  seems  to  be  the  most  generally 
successful,  and  the  result  of  a  certain  Lady  Bountiful's  practice  forms  its  best  commentary. 
She  begins  with  an  antimonial  emetic  ;  the  patient  is  washed  every  morning  with  soap 
and  water,  gets  every  second  day  half  an  ounce  of  sulphate  of  magnesia,  on  the  seventh 
day  a  blister  to  the  neck,  and  if  necessary  some  diluted  wine,  this  seldom  and  sparingly  ; 
of  120  in  fever,  treated  after  this  mechanical  plan  not  one  died."— C/igyne  and  Barker's 
Report,  p.  444. 

VOL.  I.  8 


114  CLINICAL   MEDICINE. 

nerally  followed  thirty  years  ago.  If  you  look  to  Dr.  Cheyne  and  Dr. 
Barker's  Synopsis  of  the  plan  of  treatment  employed  by  the  physicians 
of  those  days^  you  will  be  prepared^  from  a  mere  inspection  of  it,  to 
admit  that  it  was  at  least  as  hard  to  escape  the  physician  as  the  disease. 
Since  that  period  our  practice  has  greatly  improved,  and  things  are  much 
changed;  the  preponderance  of  fatal  cases  is  now  to  be  found  among 
the  poor,  and  the  mortality  among  the  rich,  or  those  who  have  proper 
medical  advice  from  the  commencement,  is  not  one  third  of  that  which 
is  found  among  the  indigent,  who  are  generally  neglected  at  the  com- 
mencement of  the  disease.  I  am  therefore  fully  prepared  to  deny  that, 
in  the  present  state  of  medical  knowledge,  our  practice  is  a  matter  of 
indifference ;  on  the  contrary,  there  is  no  disease  in  which  diligent  at- 
tention and  skiKul  treatment  are  more  frequently  successful  than  in 
fever,  nor  is  there  any  affection  of  equal  importance  in  which  our  thera- 
peutic means  are  more  efficient  and  valuable. 

Now,  when  called  on  to  treat  a  case  of  fever,  there  are  several  things 
which  require  your  attention.  In  the  first  place,  you  should  examine 
the  state  of  the  family  arrangements.  This  is  a  matter  which  men  are 
apt  to  overlook  or  treat  as  a  matter  of  indifference,  but  in  my  mind  it  is 
of  no  ordinary  importance,  and  should  be  always  attended  to.  You 
should  never,  if  possible,  undertake  the  treatment  of  a  case  of  fever 
where  the  friends  or  relations  of  the  patient  supply  the  place  of  a  regular 
fever  nurse.  The  mistaken  tenderness  of  relatives,  and  their  want  of 
due  firmness,  presence  of  mind,  and  experience,  wiU  frequently  counter- 
act your  exertions  and  mar  your  best  efforts.  Affection  and  sorrow 
cloud  the  judgment,  and  hence  it  is  that  very  few  medical  men  ever  un- 
dertake the  treatment  of  dangerous  illness  in  the  members  of  their  own 
families.  The  sympathy  which  a  nurse  should  have  for  her  patient 
should  be  grounded  on  a  general  anxiety  to  serve,  and  a  strict  sense  of 
duty,  as  well  as  a  laudable  desire  of  increasing  her  own  reputation ;  it  is, 
in  fact,  a  sympathy  analogous  to  that  which  should  actuate  a  physician. 
Again,  it  will  not  do  to  have  a  nurse  who  has  been  usually  employed  in 
other  diseases ;  your  assistant  must  be  a  regular  fever  nurse,  and  the 
man  who  undertakes  the  treatment  of  a  long  and  dangerous  case  of 
fever  without  such  an  assistant,  will  often  have  cause  to  regret  it.  I 
could  mention  to  you  many  cases  illustrative  of  the  truth  of  this  asser- 
tion. I  could  tell  you,  that  where  I  have  permitted  the  continuance  of 
the  services  of  one  of  the  family,  or  of  a  common  nurse,  I  have  been 
almost  invariably  annoyed  and  disappointed.  I  now  make  it  a  general 
rule  to  refuse  attending  any  dangerous  and  protracted  case  of  fever 
without  a  properly  quahfied  nurse. 

There  are  many  nurses  who  are  extremely  attentive,  but  inexpert  and 


CHOICE    OF   A    NURSE    IN    FEVER.  115 

injudicious^  and  their  ill-judged  attentions  are  frequently  prejudicial  to 
tlie  patient.  A  fever  nurse  has  a  vast  deal  in  her  power ;  if  an  enema 
is  to  be  administered,,  the  patient  will  be  much  less  disturbed  and  an- 
noyed than  if  it  were  given  by  an  unskilful  person.  The  mere  handhng 
of  a  patient — the  moving  of  him  from  one  bed  to  another — the  simple 
act  of  giving  liim  medicine  or  drink — the  changing  of  his  sheets  and 
linen — the  dressing  of  his  blisters — and  a  thousand  other  offices,  can  be 
performed  with  advantage  only  by  an  experienced  nurse.  Always  bear 
in  mind  that  it  is  of  the  utmost  importance  to  economise  the  patient's 
strength  in  fever.  The  very  act  of  lifting  him  up,  or  moving  him  from 
one  side  to  another,  tends  to  produce  exhaustion.  In  the  advanced 
stages  of  fever,  the  servdces  of  a  properly  qualified  nurse  are  inestimable. 
Then  there  is  the  moral  management  of  the  patient,  and  this  is  an  office 
which  no  one  can  undertake  unless  qualified  by  experience,  and  a  correct 
knowledge  of  the  habits  of  persons  labouring  under  such  forms  of 
disease.  Every  one  admits  the  value  of  moral  superintendence  in  the 
treatment  of  the  insane.  Now  there  are  very  few  patients  who  are  not 
in  a  state  analogous  to  insanity,  for  a  longer  or  shorter  period,  during  a 
course  of  typhus  fever.  There  is  a  necessity  for  moral  management  in 
fever  as  well  as  in  insanity,  and  this  is  understood  only  by  an  expe- 
rienced nurse.  Friends  or  relatives  are  seldom  found  capable  of  dis- 
charging this  office.  If  they  chance  to  discover  from  the  physician's 
remarks  or  questions,  the  weak  points  of  the  patient's  case,  they  gene- 
rally contrive  to  let  him  know  them  in  some  way  or  other.  If  the 
patient  is  restless,  for  instance,  the  ill-judged  anxiety  of  his  friends  will 
most  certainly  prevent  him  from  sleeping.  They  steal  softly  to  his  bed, 
draw  the  curtains,  move  the  candle  so  as  to  make  the  light  fall  on  his 
eyes,  and  w^ake  him  perhaps  at  the  moment  he  is  settling  down  to  rest. 
If  he  happen  to  take  an  opiate,  and  that  they  are  aware  of  the  nature  of 
his  medicine,  they  inform  him  of  it,  and  his  anxiety  for  sleep,  conjoined 
with  their  enquiries,  prevents  its  due  operation.  Hence,  when  you  pre- 
scribe an  opiate,  you  should  not  in  any  case,  say  anything  about  it ;  and 
it  should  not  be  administered  in  such  a  way  as  to  lead  the  patient  or  his 
friends  to  expect  decided  benefit  from  it.  It  is  only  where  I  have  to 
deal  with  prudent  persons  that  I  break  through  my  rule  of  conceahng 
both  the  nature  of  the  medicine  and  the  results  which  I  expect  from  its 
operation.  One  of  the  best  w^ays  of  giving  an  opiate  is  to  administer  it 
in  the  form  of  an  enema.  The  patient's  attention  is  then  turned  away 
from  the  consideration  of  loss  of  rest — he  supposes  that  the  enema  is  to 
act  on  his  bowels,  and  in  expecting  a  motion  he  drops  asleep.  You 
will  often,  too,  succeed  in  producing  sleep  in  this  way,  wdiere  you  would 
fail  in  bringing  it  on  by  an  opiate  administered  by  the  mouth.     Another 


116  CLINICAL   MEDICINE. 

recomm  en  elation  attached  to  this  mode  of  exhibiting  opiates  is,  that  it 
can  be  employed  in  cases  of  delirium,  where  the  patient  obstinately  re- 
fuses to  swallow  any  kind  of  medicine.  Let  me  give  you  here  another 
caution.  Do  not  let  the  patient  know  the  situation  or  extent  of  his 
danger,  however  you  may  feel  bound  to  act  in  reference  to  these  matters 
towards  his  relatives  or  friends.  If  you  apprehend  mischief  in  the 
brain,  do  not  commence  by  examining  the  head,  or  putting  your  ques- 
tions in  such  a  manner  as  to  lead  him  to  suspect  the  seat  and  nature 
of  the  affection.  The  same  remark  may  be  applied  to  the  examination 
of  the  thorax  and  abdomen. 

In  the  next  place,  when  treating  a  case  of  bad  typhus,  do  not  think 
that  it  will  be  sufficient  to  see  your  patient  once  a  day.  But  you  will 
say,  perhaps,  that  our  hospital  patients  here  do  very  weU,  and  yet  they 
are  visited  only  once  in  the  twenty-four  hours.  True — but  then  we 
have  experienced  nurses  to  look  after  them  at  all  hours  ;  we  have  the 
valuable  surveillance  of  our  apothecary,  Mr.  Parr ;  we  have  the  attend- 
ance of  the  resident  pupils,  and  of  the  gentlemen  who  take  charge  of 
the  cases.  You  see  then  that  they  do  not  depend  on  a  solitary  visit. 
How  often  has  Mr.  Parr,  or  the  resident  pupil,  found  it  necessary  to 
change  the  treatment  adopted  at  the  morning  visit  ?  How  often  have 
the  remedies  of  which  we  had  only  given  a  hint  in  the  morning,  been 
actively  and  energetically  employed  before  the  close  of  the  day ;  and 
how  often  have  lives  been  saved  by  the  valuable  attentions  to  which  I 
have  just  alluded?  No  one  should  attend  a  case  of  fever  without 
having  proper  medical  assistants.  My  practice,  in  general,  is  to  visit 
my  fever  patients  two  or  three  times  a  day ;  and,  when  I  have  a  bad  or  a 
dangerous  case  to  manage,  I  always  have  a  competent  medical  assistant 
to  stay  by  the  patient  and  watch  every  change  of  his  malady. 

I  do  not  know  how  they  manage  this  matter  elsewhere,  but  in  this 
city  we  have  so  many  zealous,  intelligent  students,  so  many  young  me- 
dical friends,  and  so  many  well-educated  apothecaries,  that  we  are  never 
at  a  loss  for  an  assistant.  This  fact  is,  I  think,  a  sufficient  answer  to 
the  objections  put  forward  by  Dr.  Johnson,  in  the  Medico-Chirurgical 
E^view.  He  says  that  tartar  emetic  is  a  two-edged  svvord — an  agent 
powerful  alike  for  good  or  evil,  and  in  the  administration  of  which  no 
ordinary  circumspection  is  demanded.  All  this  I  am  willing  to  admit ; 
there  is  no  remedy  capable  of  producing  more  miscliief  when  abused, 
but  when  properly  watched  it  is,  I  am  confident,  the  means  of  saving 
many  valuable  Hves.  He  says,  also,  that  Dr.  Graves  cannot  give  that 
share  of  attention  to  his  patients  which  the  employment  of  such  a  re- 
medy demands.  He  is  quite  mistaken  on  this  point.  I  am  never  at  a 
loss  for  some  skilful  person  to  remain  with  the  patient,  watch  the  ope- 


DIET    IN    FEVER.  117 

ration  of  each  dose,  and  modify  or  change  it  according  to  circumstances. 
The  want  of  proper  assistants  may  be  elsewhere  an  objection  to  the  ad- 
ministration of  tartar  emetic,  but  this  objection  does  not  hold  good  with 
respect  to  DubKn. 

One  or  two  more  observations  of  a  general  nature.  Some  persons 
have  such  a  terror  of  foul  air,  in  cases  of  fever,  that  you  will  find  all 
the  windows  in  the  house  thrown  open,  not  even  excepting  those  of  the 
patient^s  bed-chamber,  and  wherever  you  turn  you  are  sure  to  meet  with 
a  current  of  air.  Now,  this  is  an  unnecessary  practice,  likely  to  entail 
disease  on  the  family,  and  local  inflammation  on  the  patient.  The  bed- 
room of  a  patient  labouring  under  fever  should  be  well  aired,  but  with- 
out what  is  termed  thorough  air ;  and  it  should,  if  possible,  be  a  quiet 
back  room,  away  from  the  street.  In  the  next  place,  it  should  be  sufii- 
ciently  large  to  hold  two  bedsteads  conveniently ;  and  you  should  order 
the  attendants  to  have  two  well  aired  beds  in  readiness,  from  one  of 
which  the  patient  should  be  changed  to  the  other  every  twelve  or  twenty- 
four  hours.  You  can  scarcely  have  an  idea  of  the  comfort  this  aftbrds 
to  a  person  in  fever.  The  room  can  be  kept  properly  ventilated  by  a 
fire,  and  the  temperature  can  be  regulated  by  a  thermometer.  Some 
persons  are  in  the  habit  of  constantly  sprinkling  the  room  with  vinegar 
— others  with  the  clilorides.  I  do  not  know  that  it  is  necessary,  and  I 
think  that  the  use  of  chlorine  is  doubtful,  if  not  improper,  and  may 
prove  injurious  to  the  patient. 

Having  made  these  few  general  observations  on  the  steps  to  be  taken 
by  those  who  enter  on  the  treatment  of  typhus,  I  shall  now  proceed  to 
speak  of  diet  and  medicines.  In  a  disease  like  fever,  which  lasts  fre- 
quently for  fourteen,  twenty-one,  or  more  days,  the  consideration  of 
diet  and  nutriment  is  a  matter  of  importance,  and  I  am  persuaded  that 
this  is  a  point  on  which  much  error  has  prevailed.  I  am  convinced 
that  the  starving  system  has,  in  many  instances,  been  carried  to  a  dan- 
gerous excess,  and  that  many  persons  have  fallen  victims  to  prolonged 
abstinence  in  fever.  This  was  one  of  the  errors  which  sprung  from 
the  doctrines  of  those  who  maintained  that  fever  depended  on  general 
or  topical  inflammation.  They  supposed  that  fever  arose  from  inflam- 
mation, and  immediately  concluded  that,  to  treat  it  successfully,  it  was 
necessary  to  reduce  the  system  by  depletion  and  low  diet,  and  to  keep 
it  at  this  point  during  the  whole  course  of  the  disease.  Hence  the 
strict  regimen — the  diete  absolue — of  the  disciples  of  the  physiological 
school,  and  of  those  who  looked  on  inflammation  as  the  essence  of  fe- 
ver. The  more  the  symptoms  appeared  indicative  of  inflammatory 
action,  the  more  rigorous  was  the  abstinence  enforced.  If  a  patient^s 
face  was  flushed,  or  his  eyes  suffused,  no  matter  what  the  stage  of  the 


118  CLINICAL   MEDICINE. 

fever  was,  tliey  said,  "  here  is  inflammation  of  the  brain,  and  nourish- 
ment will  exasperate  it/'  If  he  had  red  or  dry  tongue,  and  abdominal 
tenderness,  they  immediately  inferred  the  existence  of  gastro-enteritis, 
and  all  kinds  of  food  even  the  lightest,  were  strictly  forbidden.  That 
tliis  proceeds  from  false  notions  on  the  nature  of  fever  is  beyond  doubt, 
and  I  pointed  out  this  fact  many  years  ago,  long  before  the  appearance 
of  Piorry's  work.  Let  us,  in  the  first  place,  examine  the  results  of 
protracted  abstinence  in  the  healthy  state  of  the  system.  Take  a  healthy 
person  and  deprive  him  of  food,  and  what  is  the  consequence  ?  Tirst, 
hunger,  which  after  some  time  goes  away,  and  then  returns  again. 
After  two  or  three  days,  the  sensation  assumes  a  morbid  character,  and 
instead  of  being  a  simple  feeling  of  want  and  a  desire  for  food,  it  be- 
comes a  disordered  craving,  attended  with  dragging  pain  in  the  stomach, 
burning  thirst,  and  some  time  afterwards,  epigastric  tenderness,  fever, 
and  delirium.  Here  we  have  the  supervention  of  gastric  disease,  and 
inflammation  of  the  brain  as  the  results  of  protracted  starvation. 

Now,  these  are  in  themselves  very  singular  facts,  and  well  deserving 
of  being  held  in  memory.  Eead  the  accounts  of  those  who  perished 
from  starvation  after  the  wreck  of  the  Medusa  and  the  Alceste,  and  you 
will  be  struck  with  the  horrible  consequences  of  protracted  hunger. 
You  will  find  that  most  of  the  unhappy  sufferers  were  raging  maniacs, 
and  exhibited  symptoms  of  violent  cerebral  irritation.  INTow,  in  a 
patient  labouring  under  the  effects  of  fever  and  protracted  abstinence — 
whose  sensibilities  are  blunted,  and  whose  functions  are  deranged — it  is 
not  at  all  improbable  that  such  a  person,  perhaps  also  suffering  from  de- 
lirium or  stupor,  will  not  call  for  food,  though  requiring  it ;  and  that  if 
you  do  not  press  it  on  him,  and  give  it  as  medicine,  symptoms  like  those 
which  arise  from  starvation  in  the  healthy  subject  may  supervene,  and 
you  may  have  gastro-enteric  inflammation,  or  cerebral  disease,  as  the 
consequence  of  protracted  abstinence.  You  may,  perhaps,  think  that 
it  is  unnecessary  to  give  food,  as  the  patient  appears  to  have  no  appe- 
tite and  does  not  care  for  it.  You  might  as  well  think  of  allowing  the 
urine  to  accumulate  in  the  bladder,  because  the  patient  feels  no  desire 
to  pass  it.  You  are  called  on  to  interfere  where  the  sensibility  is  im- 
paired, and  the  natural  appetite  is  dormant ;  and  you  are  not  to  permit 
youi*  patient  to  encounter  the  horrible  consequences  of  inanition,  be- 
cause he  does  not  ask  for  nutriment.  I  never  do  so.  After  the  third 
or  fourth  day  of  fever,  I  always  prescribe  mild  nourishment,  and  this  is 
steadily  and  perseveringly  continued  through  the  whole  course  of  the 
disease. 

Again,  let  us  see  how  close  a  resemblance  the  symptoms  generated  by 
long-continued  denial  or  want  of  food  bear  to  those  which  are  observed 


DIET  IN  FEVER.  110 

in  the  worst  forms  of  typhus.  Pain  of  the  stomach,  epigastric  tender- 
ness, thirst,  vomiting,  determination  of  blood  to  the  brain,  suffusion  to 
the  eyes,  headache,  sleeplessness,  and,  finally,  furious  delirium,  are  the 
symptoms  of  protracted  abstinence ;  and  to  these  we  may  add,  ten- 
dency to  putrefaction  of  the  animal  tissues,  chiefly  shown  by  the  spon- 
taneous occurrence  of  gangrene  of  the  lungs.  It  has  been  shown  by 
M.  Guislain,  physician  to  the  hospital  for  the  insane,  at  Gand,  that  in 
many  instances  gangrene  of  the  lungs  has  occurred  in  insane  patients 
who  have  obstinately  refused  to  take  food.  Out  of  thirteen  patients 
who  died  of  inanition,  nine  had  gangrene  of  the  lungs.  You  perceive, 
then,  that  starvation  may  give  rise  to  symptoms  of  gastric  disease,  to 
symptoms  of  cerebral  derangement,  and  to  mortification  of  the  pulmo- 
nary tissue.  It  is  not,  therefore,  wrong  to  suppose  that  when  a  system 
of  rigorous  abstinence  has  been  observed  in  fever,  and  when  food  has 
been  too  long  withheld,  because,  forsooth,  the  patient  does  not  call  for 
it,  and  because  his  natural  sensibilities  are  blunted  and  impaired — ^it  is 
not,  I  say,  unreasonable  to  infer  that  gastric,  cerebral,  and  even  pulmo- 
nary symptoms  may  supervene,  analogous  to  those  which  result  from 
actual  starvation."^ 

An  attentive  consideration  of  the  foregoing  arguments  has  led  me,  in 
the  treatment  of  long  fevers,  to  adopt  the  advice  of  a  country  physician 
of  great  shrewdness,  who  advised  me  never  to  let  my  patients  die  of 
starvation.  If  I  have  more  success  than  others  in  the  treatment  of  fe- 
ver, I  think  it  is  owing  in  a  great  degree  to  the  adoption  of  this  advice. 
I  must  however  observe,  that  great  discrimination  is  required  in  the 
choice  of  food.  Although  you  will  not  let  your  patient  starve,  do  not 
fall  into  the  opposite  extreme  :  you  must  take  care  not  to  overload  the 
stomach.  When  this  is  done,  gastro -enteric  irritation,  tympanitis,  in- 
flammation, and  exasperated  febrile  action  are  the  consequences.  I 
have  witnessed  many  instances  of  the  danger  of  repletion  in  fe- 
brile diseases.  A  case  of  this  kind  occurred  some  time  ago  in  this 
hospital,  in  a  boy  who  was  recovering  from  peritonitis.  In  an- 
other case,  in  private  practice,  an  incautious  indulgence  in  the  use  of 


*  HuxHA3i  gives  the  history  of  a  gentleman  who  obstinately  starved  himself  to  death, 
and  would  not,  for  many  days  either  by  force  or  persuasion,  swallow  any  kind  of  food,  or 
a  drop  of  liquor.  He  soon  grew  feverish,  flushed  in  his  face,  and  very  hot  in  his  head  ; 
his  pulse  was  small  but  very  quick,  in  four  or  five  days  his  breath  became  exceedingly 
oiFensive,  his  lips  dry,  black,  and  parched,  his  teeth  and  mouth  foul,  black,  and  bloody, 
his  urine  vastly  high  coloured,  and  stinking  as  much  as  if  it  had  been  kept  a  month ;  at 
length  he  trembled  continually,  could  not  stand  much  less  walk,  raved  and  dozed  alter- 
nately, fell  into  convulsive  agonies  frequently,  in  which  he  sometimes  sweated  pretty  much 
about  the  head  and  breast,  though  his  extremities  were  quite  cold,  pale  'and  shrivelled  ; 
the  sweat  was  of  a  very  dark  yellow  colour,  and  of  a  most  nauseous  stench. 


120  CLINICAL   MEDICINE. 

animal  food  was  followed  by  a  fatal  result.  A  young  lady  ate  some 
beefsteak,  contrary  to  my  orders,  at  an  early  period  of  convalescence  from 
fever,  relapsed  almost  immediately,  and  died  of  enteritis  in  thirty-six 
hours. 

Food  must  be  given  with  great  care  and  judgment,  particularly  in 
the  beginning  of  fever.  For  the  first  three  or  four  days,  particularly 
if  the  patient  be  young  and  robust,  water,  weak  barley-water,  and 
whey  wiU  be  sufficient.  After  this  it  may  be  well  to  begin  with  some 
mild  nutriment.  What  I  generally  give  is  some  well  boiled  gruel, 
made  of  groats,  and  flavoured  with  sugar,  and  if  there  be  no  tendency 
to  diarrhoea,  a  small  quantity  of  lemon  juice.  The  ordinary  oatmeal 
gruel  does  not  answer  sufficiently  well  for  this  purpose,  for  it  is  apt  to 
produce  griping  and  diarrhoea,  symptoms  wliich  are  extremely  disagree- 
able in  the  commencement  of  fever,  and  which  often  lead  to  others  of  a 
more  troublesome  and  formidable  character.  I  am  also  much  in  the 
habit  of  ordering  a  little  thin  panado,  morning  and  evening,  during  the 
latter  part  of  the  first,  and  the  beginning  of  the  middle  stage  of  fever. 
A  small  sHce  of  bread  is  slightly  toasted,  and  boihng  water  poured  on 
a  tablespoonful  of  the  crumbs,  in  sufficient  quantity  to  make  a  thin 
panado,  of  which  the  patient  takes  a  tablespoonful  two  or  three  times  a 
day.  It  may  be  flavoured  with  a  very  small  quantity  of  lemon  juice 
and  sugar,  if  there  be  no  tendency  to  diarrhoea ;  but  where  this  exists, 
or  where  you  are  administering  mercurials,  I  think  you  should  be 
cautious  in  the  use  of  acids.  Although  medical  men  of  the  present 
day  do  not  object  to  giving  acids  during  the  use  of  mercurials,  I  think 
the  practice  is  not  entirely  devoid  of  danger,  and  I  think  our  predeces- 
sors were  right  in  withholding  them  under  such  circumstances. 

You  will  begin,  then,  on  the  third,  fourth,  or  fifth  day,  according  to 
circumstances,  with  a  little  gruel ;  and  after  two  or  three  days  you  may 
add  a  httle  panado,  giving,  as  I  have  already  observed,  a  spoonful  of 
either  every  third  hour.  As  the  fever  advances  you  may  add  some 
mild  animal  jelly  or  broth ;  and  one  of  the  best  kinds  of  nutriment  in 
the  middle  and  latter  stages  of  fever,  is  chicken  broth.  I  do  not  speak 
here  of  chicken  water ;  but  I  mean  good  and  well  made  chicken  broth. 
Give  this,  but  give  it  in  small  quantities,  and  with  great  caution  at 
first.  Watch  the  effects  of  the  few  first  spoonfuls  ;  it  may  act  inju- 
riously, and  you  should  give  it  up,  at  least  for  some  time,  if  it  pro- 
duces any  bad  effects.  If  it  brings  on  heaviness,  sickness  of  stomach, 
flushing  of  the  face,  excitement  of  pulse,  and  increased  feverishness, 
give  it  up,  and  return  for  some  time  to  the  gruel  and  panado.  You 
can  try  it  again  in  a  day  or  two ;  for  although  your  patient  does  not 
bear  it  to-day,  he  may  to-morrow  or  the  day  after ;  and  it  is  a  most  for- 


DRINKS  IN  FEVEll.  121 

tunate  circumstance  when  it  agrees  with  him,  for,  as  I  have  already 
observed,  it  is  the  best  kind  of  nutriment  you  can  give  in  the  middle 
and  latter  stages  of  fever. 

Eecollecting  the  tendency  to  diarrhoea  and  intestinal  irritation  in 
fever,  you  will  be  extremely  cautious  in  allowing  your  patients  the  use 
of  fruits.  Indulging  patients  in  the  use  of  grapes  and  oranges  is  a  very 
popular,  but,  in  my  mind,  a  very  hazardous  and  improper  custom.  I 
have  on  many  occasions  seen  persons  injured  by  fruits  of  this  descrip- 
tion. Stewed  and  roasted  apples  are  still  more  dangerous ;  they  are 
apt  to  produce  tormina,  flatulence,  diarrhoea,  and  intestinal  inflammation. 
All  acid  or  raw  fruits  have  a  tendency  to  produce  irritation  of  the  sto- 
mach and  bowels,  and  should  be  avoided  altogether,  or  very  sparingly 
used. 

In  this  hospital  we  seldom  prescribe  eff'ervescing  draughts,  and 
never  give  them  in  the  ad  lihitum  quantity  which  some  persons  recom- 
mend. Thirst  can  be  sufiiciently  assuaged  by  the  use  of  whey,  or 
common  water  acidulated  with  currant  jelly  or  raspberry  vinegar,  given 
in  small  portions,  and  at  certain  intervals.  Sometimes  you  will  succeed 
effectually  in  controlling  feverish  thirst  by  the  use  of  a  very  light  in- 
fusion of  cascariUa,  acidulated  with  a  small  quantity  of  muriatic  acid. 
I  have  seen  this  employed  with  success  by  Mr.  Kirby,  and  I  have  often 
prescribed  it  myself  with  the  best  effects.  Yery  often  a  small  quantity 
of  some  light  bitter,  slightly  acidulated,  will  appease  the  morbid  thirst 
of  fever  more  effectually,  and  for  a  much  longer  period,  than  large 
draughts  of  water,  or  any  of  the  fluids  usually  employed  for  the  same 
purpose.  You  should  always  bear  in  mind,  that  thirst  in  fever  does 
not  exclusively  depend  on  a  dry  or  parched  state  of  the  mouth  or  fauces, 
but  lies  much  deeper  in  the  system,  and  has  its  origin  in  some  peculiar 
derangements  of  the  nerves,  most  probably  of  those  belonging  to  the 
ganglionic  system.  In  going  through  a  fever  ward,  you  meet  with 
numerous  illustrations  of  the  truth  of  this  position ;  one  man  with  a 
moist  tongue  and  fauces,  labours  under  insatiable  thirst,  while  you 
wiU  observe  another  with  parched  tongue  and  throat,  and  yet  without 
any  desire  whatever  for  fluids,  or  any  choice  as  to  their  temperature. 
We  had  two  examples  of  this  in  the  fever  ward  during  the  past  week. 
One  patient  with  a  moist  tongue  was  incessantly  calling  for  drink, 
while  another  man,  who  had  his  tongue  almost  perfectly  dry,  exhibited 
a  very  remarkable  indifference  to  fluids. 

One  general  observation  as  to  the  administration  of  food  and  nutri- 
ment in  fever.  All  kinds  of  food  and  nutriment  should  be  given  by 
day,  and  the  patient  should,  if  possible,  be  restricted  to  the  use  of 
fluids  by  night.     The  natural  habit  is  to  take  food  by  day  and  not  by 


122  CLINICAL   MEDICINE. 

night,  and  in  sickness  as  well  as  in  health,  we  should  observe  the  diur- 
nal revolution  of  the  economy. 

When  you  give  nutriment,  then,  be  careful  in  observing  the  usual 
periods  of  meals.  The  space  of  time  to  which  I  limit  the  giving  of 
chicken  broth,  jelly,  arrow-root,  and  other  mild  articles  of  diet,  is 
from  eight  o'clock  in  the  morning  to  eight  in  the  evening.  Always 
make  it  a  rule  that  your  patient  shall  take  nutriment  within  the  space 
of  those  twelve  hours  during  which  he  is  accustomed  to  take  his  meals 
when  in  health,  and  allow  him  notliing  but  mild  diluent  fluids  during 
the  night.  I  am  persuaded  that  I  have  seen  much  benefit  derived  from 
following  this  simple  plan. 

"With  respect  to  drinks,  the  mildest,  of  course,  should  be  preferred  : 
on  this  point  most  persons  are  generally  agreed,  and  it  will  be  unne- 
cessary for  me  to  detain  you  with  any  particular  observations.  There 
is  one  error,  however,  wliich  is  very  frequently  committed  in  the  use  of 
drinks  in  fever ;  patients  are  generally  allowed  to  drink  too  much.  It 
may  be  urged  that  they  have  a  strong  desire  for  fluids ;  but  they  should 
not  be  gratified  in  everything  they  wish  for.  They  labour  under  a  con- 
stant state  of  nervous  irritation  and  restlessness,  and  will  beg  of  you 
to  do  twenty  different  things  to  reheve  their  immediate  feelings ;  but  it 
would  be  just  as  improper  to  give  them  large  quantities  of  drink  every 
time  they  desire  to  call  for  it,  as  to  indulge  them  in  any  momentary 
whim  which  may  be  the  ofPspring  of  their  disordered  and  changeable 
fancy.  The  continued  swilHng  of  even  the  most  innocent  fluids  will 
bring  on  heaviness  of  stomach,  nausea,  pain,  and  flatulence,  and  pre- 
disposes to  congestion  and  intestinal  irritation.  Prom  the  mere  inges- 
tion of  a  large  quantity  of  the  simplest  fluid,  you  will  frequently  see 
well-marked  symptoms  of  gastric  irritation  arise  during  the  course  of 
fever.  This  is  not  a  picture  drawn  from  imagination ;  I  have  witnessed 
it  on  many  occasions  during  the  course  of  my  practice.  It  is  extremely 
painful,  indeed,  to  be  obliged  to  refuse  drink  to  a  patient  labouring 
under  intense  tliirst ;  but  you  should  never  allow  them  to  take  a  large 
quantity  of  fluid  at  a  time  :  you  should  impress  upon  them  the  danger 
attendant  on  such  a  practice,  and  tell  them  that  a  spoonful  or  two, 
swallowed  slowly,  allays  thirst  more  effectually  than  drinking  a  pint  at 
a  time.  The  sensation  of  thirst,  as  you  all  know,  is  almost  entirely 
confined  to  the  fauces  and  upper  part  of  the  phar3mx,  and  it  is  as  much 
reheved  by  a  small  quantity,  swallowed  slowly  and  gradually,  as  it  is 
by  a  large  quantity  gulped  down  at  once. 

Besides  the  simple  fluids,  there  are  other  drinks  required  in  fever. 
Beer,  ale,  porter,  wine,  tea,  and  coffee,  are  also  frequently  used  in  the 
treatment  of  fever,  and  are  of  the  utmost  value  when  employed  on 


THE  GENERAL  TREATMENT  OF  FEVER.  123 

appropriate  occasions;  they  are  adjuvants  of  the  highest  importance  in 
the  dietetic  management  of  fever,  and  it  will  require  some  time  to  ex- 
plain the  rules  by  which  you  should  be  guided  in  their  administration. 
I  shall  therefore  speak  of  them  according  to  the  indications  with  which 
they  are  given ;  and  first  of  tea  and  coffee. 

You  are  aware  that  we  give  sedatives  and  narcotics  to  tranquillise, 
to  produce  a  species  of  exhaustion  of  the  mental  faculties,  and  to  bring 
on  sleep ;  and  I  do  not  see  any  reason  why  we  should  not  also  admi- 
nister expergefacients,  or  remedies  calculated  to  maintain  intellectual 
activity,  and  keep  the  patient  awake.  Among  the  remedies  most  fre- 
quently employed  for  the  latter  purpose  are  tea  and  cofiee.  You  have 
lately  seen  an  infusion  of  green  tea  useful  in  a  case  of  narcotism  which 
occurred  in  the  fever  ward.  A  man  in  the  latter  stage  of  fever,  and 
labouring  under  great  nervous  excitement  and  total  loss  of  sleep,  was 
ordered  an  opiate  enema,  after  we  had  tried  various  other  means  without 
success.  During  the  course  of  the  evening  he  got  twelve  drops  of 
black  drop,  with  two  ounces  of  mucilage  of  starch,  in  the  form  of 
enema,  and  soon  after  fell  into  a  sound  sleep.  When  we  came  next 
morning  and  enquired  after  him,  everything  was  reported  to  have  gone 
on  well ;  the  opiate  enema  had  answered  the  purpose  completely,  and 
the  man  was  still  sleeping  deeply.  We  found,  however,  on  a  more 
accurate  examination,  that  he  was  in  a  kind  of  lethargic  state,  and 
could  scarcely  be  roused.  When  addressed  in  a  loud  tone  of  voice,  he 
raised  himself  heavily  and  slowly,  half  opened  his  eyes,  gave  a  brief 
answer  to  our  questions,  and  then,  leaning  back  on  his  piUow,  dropped 
asleep.  Observe  here  the  danger  connected  with  this  state.  He  was 
in  an  advanced  stage  of  fever,  had  been  restless  and  sleepless,  and  had 
suddenly  passed  to  an  opposite  state.  The  rapidity  with  which  coma 
had  supervened  on  sleeplessness,  and  the  danger  of  fatal  congestion  of 
the  brain  coming  on,  gave  me  considerable  alarm.  There  was  no  use, 
however,  in  thinking  of  what  had  been  done ;  the  man^s  state  called 
for  prompt  and  decided  measures,  and  we  proceeded  at  once  to  attack 
the  symptoms  of  our  own  creation.  One  of  the  gentlemen  went  down 
and  got  some  green  tea,  of  which  he  made  a  strong  infusion,  and  ad- 
ministered a  strong  dose  of  it  to  the  patient.  This  had  the  desired 
effect ;  the  symptoms  of  coma  gradually  disappeared,  and  when  I  came 
to  see  him  in  the  afternoon,  he  was  quite  out  of  danger.  Green  tea 
was  first  introduced  here  as  an  expergefacient  in  the  treatment  of  coma 
by  Dr.  Edward  Percival,  son  of  Dr.  Percival  of  Manchester ;  and  some 
years  ago  he  read  a  paper  at  a  meeting  of  the  College  of  Physicians,  in 
which  he  brought  forward  several  cases  of  coma  and  stupor,  in  which 
green  tea  had  produced  the  most  favourable  effects.     On  'the  continent 


124  CLINICAL  MEDICINE. 

they  generally  use  strong  coffee  for  the  same  purpose.  Whether  these 
beverages  produce  this  effect  by  their  influence  on  the  circulation,  or 
on  the  nervous  system,  I  am  not  prepared  to  say ;  but  there  cannot  be 
a  doubt  of  their  efficacy  and  value  in  many  cases  of  this  description ; 
and  I  am  frequently  in  the  habit  of  using  both  with  this  intention. 

Wliile  on  the  subject  of  expergefacients,  I  shall  beg  leave  to  read  for 
you  a  very  curious  case  from  the  13th  number  of  the  Boston  Medical 
and  Surgical  Journal,  in  which  -an  expergefacient  of  a  less  agreeable 
character  was  employed  to  rouse  a  patient  from  the  lethargic  stupor 
brought  on  by  a  large  dose  of  laudanum.  There  are  some  transatlantic 
peculiarities  of  expression  in  the  details  of  this  case,  but  I  have  no 
doubt  of  its  being  correct.  It  is  entitled  "  a  case  of  successful  treat- 
ment by  flagellation,  where  a  large  dose  of  laudanum  had  been  taken." 
And  the  author.  Dr.  Joseph  Barrett,  of  Middleton,  Connecticut,  pro- 
ceeds as  follows  : — 

"  Tincture  of  opium  is  not  unfrequently  resorted  to  for  destructive 
purposes.  It  is  also,  unfortunately,  and  too  frequently,  taken  by  mis- 
take, and  proves  fatal  before  efficient  means  can  be  adopted  to  coun- 
teract its  deleterious  effects  on  the  system.  I  am  induced,  therefore, 
to  offer  a  short  statement  of  a  case  of  poisoning  with  laudanum  that 
fell  under  my  care  several  years  since,  for  the  following  reasons  :  first, 
the  success  that  attended  the  mode  pursued ;  and,  secondly,  not  having 
met  with  any  such  means  recorded,  to  my  knowledge,^  either  in  works 
on  medicine,  or  in  treatises  on  poisons." 

Observe,  it  is  not  I  that  am  speaking  here,  but  Dr.  Barrett,  of  Mid- 
dleton, Connecticut. 

"  In  the  year  1822,  February  23d,  I  was  called  on  to  see  Mr.  Wright 
Harris,  (this  was  in  the  state  of  New  York,)  who  had  intentionally 
taken  a  large  dose  of  laudanum  for  the  purpose  of  destroying  himself. 
He  had  committed  this  act  during  his  absence  from  home,  under  cir- 
cumstances which  it  is  not  important  to  relate.  Much  time  (about 
three  hours)  was  therefore  lost,  before  any  effectual  measures  could  be 
adopted  for  liis  rehef.  His  case,  as  I  found  him,  appeared  to  be  alto- 
gether hopeless.  Before  my  arrival,  emetics  and  various  drinks  had 
been  tried,  besides  frictions,  and  constant,  though  ineffectual  attempts, 
had  been  made  to  irritate  the  oesophagus  by  feathers.  All  these  means 
had  failed,  and  the  patient  was  in  such  a  profound  sopor,  that  appa- 
rently notliing  but  warmth  remained  to  indicate  that  life  had  not  already 
become  extinct.     The  quantity  of  laudanum  taken  was  ascertained  to 

*  This  practice,  though  not  generally  adopted,  has  been  recommended  by  several  au- 
thors  in  Europe. 


THE  GENERAL  TREATMENT  OF  FEVER.  125 

be  one  ounce  and  a  half.  Tlie  case  appearing  so  desperate^  justified 
me  in  the  course  of  treatment  which  I  was,  under  existing  circumstances, 
then  obh'ged  to  adopt. 

"  Internal  remedies  having  entirely  failed,  there  was  no  chance  left 
but  for  high  external  excitements.  I  therefore  determined  to  use 
vigorous  measures.  I  commenced  with  flagellations,  using  long  pliant, 
fresh  twigs,  to  the  palms  of  the  hands  and  soles  of  the  feet.  These 
were  briskly  applied,  and  in  a  short  time  gave  indications  of  uneasiness 
and  pain.  This  treatment  was  unremittingly  pursued  till  the  man 
spoke,  and  complained  of  being  pained  by  the  whipping,  when  this 
severe  appliance  was  relaxed ;  but  on  so  doing,  he  instantly  sunk  into 
a  profound  stupor,  from  which  he  was  again  only  roused  by  the  severity 
of  the  whipping.  It  required  the  aid  of  a  number  of  men  to  take 
turns  in  the  flagellation,  as  well  as  to  support  and  walk  him  about;- for 
a  cessation  of  the  use  of  the  rods  was  followed  by  instantaneous  stupor. 
After  about  six  or  eight  hours  under  this  course,  the  stupor  was  les- 
sened, and  the  severity  of  the  flagellation  mitigated ;  but  as  the  case 
required  constant  high  excitement,  it  was  still  repeated  at  intervals,  till 
eventually  the  exercise  of  walking  was  sufficient  to  keep  him  awake. 
This  was  in  about  twelve  hours  from  the  commencing  with  the  flagella- 
tion. He  afterwards  experienced  but  little  inconvenience  from  his  hands 
and  feet,  and  was  perfectly  restored  in  a  few  days  to  his  usual  health. 
I  would  here  state  that  the  first  proposal  made  by  me  to  adopt  flagella- 
tion, as  the  only  hope,  was  objected  to  by  the  persons  present,  from  its 
carrying  with  it  the  semblance  of  unkindness  towards  what  was  regarded 
by  them  as  a  corpse ;  and  it  was  not  till  the  application  of  the  rods  by 
myself,  in  the  first  instance,  that  I  obtained  the  aid  of  those  present ; 
but  as  soon  as  the  patient  began  to  move,  and  at  last  spoke,  they  took 
hold  with  alacrity,  and  by  dividing  themselves  into  relief  parties,  they 
very  cheerfully,  and  rather  amusingly,  kept  up  the  castigation  so  long 
as  the  state  of  the  patient  required  it  at  their  hands.  He  by  no  means 
seemed  to  relish  this  harsh  proceeding,  and  in  return  gave  his  attendants 
several  severe  blows.  If  while  lifting  his  arm  to  give  a  blow,  the  flagel- 
lation was  then  entirely  suspended,  the  arm  would  instantly  sink  pow- 
erless ;  to  such  a  degree  had  the  effects  of  the  narcotic  drug  prevailed 
over  the  nervous  system,  that  nothing  but  the  torture  of  the  rods  could 
rouse  him.  On  his  recovery,  it  was  said  that  the  man's  wife  was  highly 
satisfied  with  this  remedial  course,  which  was  believed  to  have  a  good 
effect  upon  his  subsequent  conduct." 

I  have  already  alluded  to  the  abuse  of  soda  or  seltzer  water,  and 
effervescing  draughts  in  fevers.  It  is  very  much  the  custom  both  in 
hospital  and  private  practice,  to  look  upon  the  latter  as  a  remedy  which 


126  CLINICAL    MEDICINE. 

may  be  administered  at  the  pleasure  of  the  patient,,  or  the  discretion  of 
the  nurse.  They  are  certainly  to  many  persons  a  most  grateful  means 
of  cooling  thirst ;  but  the  cautious  physician  will  never  allow  his  patient 
to  indulge  too  much,  for  he  knows  that  their  frequent  use  distends 
the  stomach,  and  produces  a  tendency  to  tympanitis,  and  bowel  com- 
plaint. I  am  also  of  opinion  that  the  exhibition  of  large  quantities  of 
free  carbonic  acid  is  a  very  doubtful,  if  not  a  dangerous,  practice  in 
fever,  and  may  increase  that  tendency  to  narcotism  and  functional  de- 
rangement of  the  nervous  and  respiratory  systems,  which  is  observed  in 
every  case  of  genuine  typhus.  In  addition  to  this,  the  evolution  of  a 
large  quantity  of  fixed  air  in  the  stomach  frequently  causes  a  very  dis- 
agreeable sense  of  distention  and  suffocation,  and  acts  injuriously  on  the 
mucous  membrane. 


127 


r 


LECTURE  X. 

GENERAL   TREATMENT    OF    FEVER. TYMPANITIS. HICCUP. 

HEMORRHAGE    FROM    THE    BOWELS. 

Before  I  proceed  to  speak  further  of  the  diet  and  remedies  to  be  em- 
ployed in  the  treatment  of  typhus  fever,  allow  me  to  make  a  few  observa- 
tions. There  is  a  patient  at  present  in  the  fever  ward,  whose  case  shows 
the  necessity  of  strict  attention  and  incessant  watchfulness  on  the  part  of 
those  who  have  the  management  of  bad  cases  of  fever.  A  man  who 
has  been  labouring  under  delirium,  with  symptoms  of  cerebral  excite- 
ment and  congestion,  was  ordered  the  tartar  emetic  solution,  with  the 
view  of  reducing  the  increased  vascular  action ;  but  on  inquiry  this 
morning,  we  find  that  he  has  taken  no  medicine,  and  that  his  symptoms 
have  been  allowed  io  go  on  unchecked  for  twenty-four  hours.  He  re- 
fused to  take  his  medicine,  and  the  nurse  very  improperly  neglected  to 
report  the  circumstances  of  the  case,  in  order  that  proper  steps  might 
be  taken  to  remedy  so  dangerous  an  omission.  Thus  a  whole  day  has 
been  lost  at  a  most  critical  and,  important  period  of  fever.  There  can 
be  no  excuse  for  such  negligence  as  this,  for  it  could  be  easily  reme- 
died. Patients  in  this  state  have  always  more  or  less  thirst,  and  a 
spoonful  of  the  tartar  emetic  solution  could  be  mixed  with  whey  or  cold 
water,  and  administered  in  this  way  without  his  knowledge,  or  if  he 
refused  to  drink  any  fluid,  it  might  be  given  in  the  form  of  enema. 
There  is  no  excuse,  therefore,  for  such  negligence ;  and  when  you  recol- 
lect the  state  that  such  patients  are  in — their  nervous  excitement,  in- 
cessant raving,  agitation,  struggling,  and  sleeplessness — you  will  be  able 
to  appreciate  the  dangerous,  and  even  fatal,  consequences  that  may  arise 
from  culpable  neglect  of  this  kind. 

At  our  last  meeting  I  spoke  of  the  use  of  food  and  drink,  and  laid 
before  you  my  views  of  the  most  appropriate  articles  of  diet  in  the 
various  stages  of  fever.  I  told  you  that  I  attributed  mugh  importance 
to  the  use  of  a  proper  regimen,  and  that  I  looked  upon  the  observance 


128  CLINICAL   MEDICINE. 

of  this  principle  as  a  main  cause  of  success  in  tlie  treatment  of  typhus. 
I  tliink  it  is  cliieflj  owing  to  our  care  in  this  respect,  that  so  few  of 
our  patients  have  tympanitis.  Now  and  then  we  have  cases  of  fever 
with  tympanitis  and  diarrhoea,  but  in  the  majority  of  instances,  these 
are  persons  who  have  been  under  treatment  before  admission,  and  who 
have  been  too  much  purged.  The  use  of  drastic  purgatives  in  the 
early  and  middle  stages  of  typhus,  is  one  of  the  most  fertile  sources  of 
subsequent  evil,  and  there  are  few  evils  of  greater  magnitude  than  tym- 
panitis with  diarrhoea,  and  gastro-enteric  inflammation,  particularly 
in  the  latter  stage  of  fever.  Now,  if  you  inquire  into  the  history  of 
the  cases  in  which  these  symptoms  are  most  distinctly  marked,  you  wiU 
find  that  in  at  least  two-thirds,  powerful  cathartics  have  been  employed 
not  once,  but  repeatedly,  in  the  commencement  of  the  disease.  Almost 
all  cases  in  which  calomel  and  colocynth,  or  aloes,  followed  by  black 
draught,  have  been  liberally  used  in  the  commencement,  become  tym- 
panitic, and  frequently  at  a  very  early  period."^     The  same  mischief, 

*  The  views  of  Dr.  Stokes  quite  agree  with  mine — 

"  A  common  practice  lias  prevailed  in  these  countries,  and,  indeed,  still  exists  to  a 
very  great  extent,  of  making  the  patient  take  a  purgative  medicine  every  day  ;  and  this, 
I  regret  to  say,  is  too  often  done  even  in  cases  where  the  surface  of  the  small  intestine 
presents  extensive  patches  of  ulceration.  Now,  I  will  ask  you,  tan  anything  he  so  bar- 
barous as  this,  or  can  it  be  exceeded  in  folly  or  mischief  by  the  grossest  acts  of  quackery  ? 
Here  we  have  an  organ  in  a  state  of  high  irritation,  and  exhibiting  a  remarkable  excite- 
ment of  its  circulation ;  and  yet  we  proceed  to  apply  stimulants  to  that  organ,  and  to 
increase  the  existing  irritation.  Would  it  not  be  absurd  in  a  case  of  inflammation  of  the 
knee  or  elbow  joint  to  direct  a  patient  to  use  constant  exercise  and  motion  ?  Would  it 
not  be  a  very  strange  practice  to  apply  irritants  to  a  raw  and  excoriated  surface  ?  Yet 
something  equally  absurd,  and  equally  mischievous,  is  done  by  those  who  employ  vio- 
lent purgatives  in  a  case  of  inflammation  of  the  digestive  tube  in  fever.  This  has  been 
the  great  blot  in  the  history  of  British  practice.  Calomel,  and  black  bottle,  and  even 
jalap,  and  aloes,  and  scammony,  have  been  prescribed  for  patients  labouring  under  se- 
vere and  extensive  dothinenteritis.  Morbid  stools  are  discharged,  and  the  more  morbid 
they  are,  the  more  calomel  and  purgatives  does  the  physician  give  to  change  their  cha- 
racter, and  bring  them  back  to  the  standard  of  health.  I  want  words  to  express  the  hor- 
rible consequences.  Too  often  have  I  seen  fever  patients  brought  into  the  hospital  with 
diarrhoea,  hypercatharsis,  and  inflammation  of  the  mucous  membrane,  from  the  use  of 
purgatives  administered  before  their  admission.  Practitioners  will  not  open  their  eyes. — 
They  give  purgatives  day  after  day,  a  very  easy  practice,  and  one  for  which  there  are 
plenty  of  precedents ;  but  it  is  fraught  with  the  most  violent  consequences.  I  will  freely 
admit  that  the  disciples  of  the  school  of  Broussais  have  gone  too  far  in  decrying  the  use  of 
laxatives  altogether.  But  if  they  have  lost  hundreds  by  this  error,  British  practitioners 
have  killed  thousands  by  an  opposite  plan  of  treatment.  In  cases  of  fever  where  there  is 
no  decided  symptom  of  gastro-enteric  disease,  there  can  be  no  objection  to  the  use  (tf  lax- 
atives, if  required^  but  they  should  always  be  of  the  mildest  description.  You  will  gain 
nothing  by  violent  purging  in  fever,  mild  laxatives  alone  can  be  employed  ;  and  where 
there  is  any  sign  of  intestinal  irritation  present,  even  these  should  be  used  with  caution. 
There  is  one  way  of  opening  the  bowels,  which  you  may  always  have  recourse  to  with 
advantage  in  fever,  viz.,  the  use  of  enemata.  There  is  not  the  slightest  doubt  that  occa- 
sionally accumulations  of  fecal  matter  will  take  place,  and  tend  to  keep  up  irritation  ; 
but  they  should  always  be  removed  with  the  least  risk  of  producing  bad  consequences. 


TYMPANITIS    IN    FEVER.  129 

but  in  a  less  degree,  is  apt  to  occur  where  a  system  of  strict  abstinence 
has  been  enforced,  and  continued  undeviatingly  for  a  considerable 
length  of  time.  Want  of  food,  even  in  the  healthy  state  of  the  system, 
is  apt  to  produce  flatulence,  weakness,  and  distention  of  the  stomach  ; 
and  in  many  instances  gives  rise  to  very  serious  forms  of  gastro-intes- 
tinal  irritation.  The  diete  ahsolue  is  very  apt  to  produce  the  same  effect 
in  fever.  Even  the  abuse  of  drinks  of  the  simplest  and  most  innocent 
description,  is  apt  to  produce  flatulence,  distention,  and  a  tendency  to 
tympanitis.  Hence  the  value  of  the  rule  which  I  laid  down  in  my  last 
lecture,  viz.,  to  allow  the  patient  only  small  portions  at  a  time,  and  to 
order  him  to  swallow  them  slowly.  The  abuse  of  the  ordinary  drinks, 
as  common  water,  whey,  barley-water,  soda  and  selters  waters,  and 
efi'ervescing  draughts,  is  a  frequent  source  of  tympanitic  swelling  in 
fever. 

Having  commenced  the  subject  of  tympanitis  in  fever,  I  cannot  do 
better  than  proceed  now  to  describe  its  causes,  and  the  mode  of  treating 
it  which  I  have  found  most  effective. 

The  mucous  membrane  of  the  ahmentary  canal  secretes  air  in  great 
abundance  during  health.  The  immediate  uses  of  the  secretion  have 
not  been  enough  studied,  nor  have  I  now  sufficient  time  to  dwell  on 
this  subject ;  it  may  be  remarked,  however,  that  the  presence  of  air  in 
the  bowels  must  be  of  great  importance,  both  physically  and  chemically 
assisting  digestion,  which  essentially  consists  in  the  gradual  softening 
and  final  solution  of  the  solid  food,  and  the  absorption  of  the  dissolved 
portions.  Physically,  the  air  must  facilitate  the  motions  of  the  ali- 
mentary bolus,  keeping  the  bowel  in  a  suitable  state  of  distention,  and 
being  ready  immediately  to  occupy  the  place  of  the  solid  or  fluid  con- 
tents as  they  are  moved  about  or  absorbed ;  chemically,  it  is  well  known 
that  certain  gases,  such  as  carbonic  acid — a  gas  always  very  abundant 
in  the  intestine,  possess  a  remarkable  power  of  rendering  various  soHds 
more  readily  soluble  in  water,  particularly  when  these  gases  are  sub- 
jected to  the  effects  of  pressure  in  close  vessels  along  with  the  solvent 
fluid,  a  state  of  things  which  exists  also  in  the  intestines  :  another 
chemically  powerful  gas  secreted  by  the  mucous  membrane  of  the  bowels 
is  sulphuretted  hydrogen.  In  the  upper  portion  of  the  canal  common 
air  is  most  abundant ;  in  the  lower  the  two  other  gases  become  predo- 
minant— a  distribution  not  fortuitous,  but  no  doubt  destined  to  fulfil 
important  purposes.  It  appears,  indeed,  that  those  portions  of  the 
alimentary  canal,  which  secrete  fluid  acids  (the  muriatic  and  acetic),  do 

To  purge  in  fever,  when  intestinal  irritation  is  present,  is  a  practice  op.posed  alike  to 
theory  and  experience,  and  1  have  already  stated  that  its  results  are  most  horrible.'' — 
Dr.  Stokes'  Lectures^  American  edition,  p.  500. 

VOL.  I.  9 


130  CLINICAL   MEDICINE. 

not  secrete  acid  gases,  while  the  remaining  portions  secrete  these  gases 
in  great  abundance,  so  that  the  one  may  be  considered  as  supplemental 
to  the  other. 

I  am  not  aware  that  physiologists  have  as  yet  considered  this  subject 
in  the  point  of  view  here  brought  forward,"^  although  it  evidently  illus- 
trates many  things  connected  with  practice.  Thus,  I  have  frequently 
remarked,  and  I  would  call  attention  to  the  fact,  that  in  persons  labour- 
ing under  dyspepsia,  and  in  whom  the  derangement  appears  to  be  li- 
mited to  the  stomach,  the  supplementary  digestion  in  the  small  intestines 
appears  to  be  carried  on  with  great  activity.  Such  persons  suffer  much 
immediately  after  having  taken  food;  they  experience  an  oppressive 
sense  of  weight  about  the  stomach,  with  flatulence  and  distention ; 
in  fact,  they  feel  exceedingly  uncomfortable  until  the  food  passes 
into  the  duodenum,  where  the  digestive  power  is  in  full  vigour  and 
activity.  As  soon  as  this  occurs,  the  sense  of  weight  and  distention 
rapidly  disappears,  and  they  are  no  longer  troubled  with  flatulence.  I 
have  further  noticed,  that  such  persons  do  not  lose  flesh  or  strength, 
and  an  inspection  of  their  alvine  discharges  has  shown  that  every  par- 
ticle of  nutritious  principle  has  been  absorbed,  and  found  its  way  into 
the  system.  This  I  have  frequently  observed.  Persons  wiU  apply  for 
advice  who  have  been  for  a  long  time  labouring  under  symptoms  of 
derangement  of  the  stomach ;  yet  they  are  by  no  means  emaciated,  and 
are  quite  capable  of  discharging  the  duties  of  situations  which  require 
great  mental  and  bodily  activity.  This  shews  that  if  the  process  of 
digestion  does  not  go  on  weU  in  the  stomach,  it  must  somewhere 
else.  If,  in  such  a  case,  the  stomach  is  weak  and  unable  to  perform 
its  functions,  the  remaining  part  of  the  digestive  tube  is  strong,  and 
pours  out  the  fluids  necessary  for  completing  the  process  with  great 
energy. 

Again,  we  meet  with  many  persons  who  never  complain  of  acidity, 
pain,  flatulence,  or  sense  of  distention  and  weight  in  the  stomach,  and 
yet  they  are  frequently  annoyed  with  unpleasant  abdominal  sensations ; 
they  have  costive  or  irregular  bowels,  diarrhea,  tormina,  tympanitis, 
fetid  unhealthy  evacuations,  and  scanty  high-coloured  urine.  They 
feel  uncomfortable,  not  immediately  after  a  meal,  but  in  three  or  four 
hours ;  they  lose  flesh  and  strength,  and  have  a  pale,  sallow,  unhealthy 
look.  Here  the  dyspepsia  is  intestinal ;  the  stomach  works  well,  and 
performs  its  functions  with  vigour,  but  when  the  alimentary  mass  en- 
ters the  small  intestines,  it  produces  a  great  deal  of  discomfort,  because 


*  This  view  of  the  uses  of  air  in  the  alimentary  canal,  first  published  by  me  in  1836, 
has  been  completely  verified  by  the  subsequent  researches  of  Liebig. 


TYMPANITIS    IN    FEVER.  131 

the  supplementary  digestion  is  deranged,  and  its  performance  attended 
with  much  labour  and  difficulty. 

In  some  cases  both  these  forms  of  dyspepsia  are  combined,  and  these 
are,  of  course,  the  worst ;  but  they  exist  quite  distinct  from  each  other, 
and  a  patient,  with  his  stomach  in  a  perfectly  normal  and  healthy  state, 
may  labour  under  dyspepsia  from  derangement  of  the  digestive  func- 
tions of  the  small  intestines,  or  with  the  latter  in  a  healthy  state,  he 
may  have  indigestion  from  simple  gastric  derangement.  We  have, 
indeed,  reason  to  conclude,  that  when  organic  or  functional  disease  so 
impairs  the  energies  of  the  stomach  that  it  assists  but  little  in  the  per- 
formance of  digestion,  the  intestinal  digestion  becomes  more  intense ; 
it  is  only  thus  that  we  can  account  for  the  absence  of  emaciation  in 
certain  cases,  such  as  that  of  Napoleon  Buonaparte,  where  nevertheless 
the  stomach  was  so  extensively  disorganized  as  totally  to  prevent  its 
taking  any  part  in  the  process  of  digestion. 

The  preceding  remarks,  though  not  directly  connected  with,  are  ne- 
vertheless illustrative  of  the  subject  under  consideration — it  being  evi- 
dent that  the  secretion  of  air  natural  to  the  mucous  membrane  of  the 
intestines  during  health,  may  readily  be  augmented  in  disease,  so  as  to 
give  rise  to  intestinal  tympanitis.  This  happens  in  all  cases  where  in- 
flammation or  congestion  attacks  this  tissue — an  occurrence  particularly 
frequent  in  fever.  When  tympanitis  takes  place  in  the  commencement 
of  fever,  it  invariably  proceeds  from  inflammation,  and  is  usually  pre- 
ceded by  tenderness  and  other  unequivocal  symptoms  of  inflammatory 
action  within  the  abdominal  cavity.  The  remedy  for  this  complication 
consists  in  local  blood-letting  freely  applied,  together  with  small  doses 
of  Dover^s  powder,  and  considerable  doses  of  hydrargyrum  cum  creta  : 
all  active  aperients  should  be  avoided,  but  emolHent  lavements  are  often 
useful. 

When  tympanitis  occurs  during  the  middle  or  latter  stages  of  pro- 
tracted fever,  it  is  sometimes  inflammatory,  but  more  frequently  depends 
on  a  state  of  venous  congestion ;  occupying  a  considerable  extent  of  the 
mucous  membrane  of  the  small  intestines,  which  subsequently  becomes 
gorged  with  blood,  and  livid,  and  secretes,  among  other  morbid  matters, 
a  large  quantity  of  gases.  This  tympanitis  is  often  preceded  by  bowel 
complaint,  unaccompanied  by  abdominal  tenderness  or  pain,  in  the  first 
instance — a  state  of  things  which  may  last  for  one  or  several  days  before 
inflation  of  the  intestines  commences.  When  this  occurs,  then,  if  it 
proceeds  rapidly,  the  belly  becomes  painful  and  somewhat  tender  on 
account  of  the  sudden  distention ;  and  a  superficial  observer  is  thus  apt 
to  attribute  the  tympanitis  to  active  inflammation. 

Now,  as  this  state  of  things  takes  place  at  a  period  of  great  debility, 


182  CLINICAL   MEDICINE. 

when  the  powers  of  life  are  already  much  exhausted,  and  when  even 
the  application  of  a  few  leeches  may  be  followed  by  alarming  weakness, 
it  is  evident  that  this  tympanitis  must  be  treated  in  a  manner  different 
from  that  above  spoken  of.  In  general,  it  will  be  right  to  commence 
with  the  exhibition  of  ten  or  fifteen  grains  of  magnesia,  with  the  same 
quantity  of  rhubarb,  given  in  some  carminative  vehicle,  such  as  spear- 
mint or  fennel  water ;  after  this  has  operated,  the  belly  should  be  well 
stuped  and  rubbed  with  a  stimulating  terebinthinate  liniment.  It  often 
happens,  that  after  the  operation  of  the  rhubarb,  the  diarrhoea,  and 
with  it  the  tympanitis,  begins  sensibly  to  diminish,  and  then  a  little 
care  soon  removes  these  symptoms  altogether.  Sometimes,  however, 
no  such  improvement  follows ;  and  the  belly  continues  to  swqil,  while 
the  bowel  complaint  is  unchecked.  This  is  a  dangerous  crisis,  and 
requires  the  utmost  judgment  in  its  treatment. 

It  is  of  great  consequence  to  remark,  that  when  the  bowel  complaint 
has  preceded  intestinal  tympanitis  in  fever,  and  when,  notwithstanding 
the  continuance  of  the  bowel  complaint,  the  tympanitis  has  gone  on 
increasing,  oil  of  turpentine  will  seldom  be  of  the  least  use,  whether 
exhibited  by  the  mouth  or  in  an  enema.  We  must,  therefore,  under 
these  circumstances,  look  for  some  remedy  different  from  those  usually 
recommended,  and  such  remedy  we  possess  in  the  acetate  of  lead. 

Pathologists  are  agreed  that  venous  congestion  and  active  inflamma- 
tion of  the  mucous  membrane  of  the  intestinal  canal  may  often  be  as- 
sociated together ;  and,  in  fact,  although  these  two  states  are  different, 
and  require  different  remedies,  yet  they  so  nearly  approach  each  other 
as  to  require  medicines  taken  from  the  class  of  antiphlogistics ;  the  one 
requires,  however,  a  very  different  antiplilogistic  from  the  other,  just 
as  chronic  dysentery  must  be  combated  by  remedies  different  from  those 
suited  to  acute  bowel  complaints.  Oil  of  turpentine  is  admirably  suited 
to  the  cure  of  congestive  tympanitis  in  fever,  where  no  bowel  complaint, 
or  a  very  slight  one,  has  preceded  or  accompanied  it.  But  is  oil  of 
turpentine  an  antiphlogistic  remedy  ?  I  answer,  does  it  not  cure  cer- 
tain cases  of  iritis,  of  sciatica,  and  of  epilepsy  ?  AVhen,  however,  a 
bowel  complaint  forms  the  chief  feature  in  a  patient's  state,  and  is 
associated  with  tympanitis,  then  the  acetate  of  lead  must  be  our  sheet 
anchor. 

I  was  first  led  to  use  this  medicine  in  considerable  doses,  in  the 
latter  stages  of  protracted  fever,  on  the  recommendation  of  Dr.  Bardsley, 
for  the  purpose  of  preventing  that  state  of  the  bowels  which  so  insi- 
diously leads  to  ulceration  of  Peyer's  glands.  Dr.  Bardsley  certainly 
deserves  much  credit  for  the  introduction  of  this  remedy,  with  which  I 
became  familiar  in  consequence  of  using  it  largely  in  xVsiatic  cholera — 


TYMPANITIS    IN    TEVER.  ]  .'33 

a  disease  iii  wliich  the  serous  discharges  are  ahnost  invariably  preceded, 
and,  when  the  patient  recovers,  invariably  followed,  hy  a  copious  secre- 
tion  of  air  into  the  bowels.  This  it  was  that  led  me  to  observe  the 
anti-tympanitic  properties  of  the  sugar  of  lead ;  for  I  found  it  to  be  a 
remedy,  not  merely  for  the  secretion  of  serous  fluid  into  the  intestines^ 
hut  for  the  secretion  of  air  in  that  disease.  Afterwards,  analogy  led 
me  to  apply  it  to  the  cure  of  tympanitis,  combined  witli  diarrhoea,  in 
the  middle  or  latter  stages  of  fever ;  and  I  have  had  much  reason  to 
congratulate  myself  upon  this  new  application  of  the  remedy,  for  it  has 
been  very  successful  in  my  hands.  It  may  be  well  to  observe,  that 
sugar  of  lead,  besides  its  astringent,  seems  to  possess  antiphlogistic 
properties ;  otherwise  we  could  scarcely  account  for  its  good  effects  in 
active  hemorrhage  and  in  violent  action  of  the  heart,  for  which  latter, 
when  given  in  large  doses,  it  is  much  celebrated  in  France. 

In  the  above  sketch  of  the  treatment  of  tympanitis,  my  chief  object 
being  to  point  out  the  circumstances  in  which  acetate  of  lead  or  turpen- 
tine may  be  used,  I  have  omitted  mentioning  many  other  remedies  and 
methods  of  treatment  as  being  sufficiently  known  to  practitioners  in  ge- 
neral ;  among  these,  probably  none  is  more  effectual  than  leeching  the 
anus  in  inflammatory  cases,  and  in  all,  mercurial  dressing  applied  over 
a  very  large  vesicated  surface  on  the  abdomen. 

Oil  of  turpentine  is  useful  not  only  in  the  tympanitis  of  fever,  but 
also  in  the  delirium  which  attends  the  low  stage  of  that  disease.  You 
mU  meet  cases  of  fever,  where  depletion  and  blistering  have  been 
carried  to  their  full  extent,  and  yet  your  patient^s  head  remains  affected ; 
his  eye  is  clear,  intelligent,  and  free  from  suffusion,  but  he  raves  at  in- 
tervals, gropes  with  his  hands,  picks  the  bed-clothes,  and  grinds  his 
teeth.  Here  we  have  not  only  an  affection  of  the  brain,  but  we  observe, 
in  the  last-mentioned  symptoms,  one  of  the  signs  of  intestinal  irritation. 
In  such  cases,  the  vital  energies  are  much  depressed ;  you  cannot  use 
leeches  or  bhsters  or  other  depletory  measures,  it  would  be  a  great  mis- 
take to  employ  them.  What  are  you  to  do  ?  prescribe  opium  in  mo- 
derate doses  and  at  certain  intervals,  as,  for  instance,  from  five  to  eight 
drops  of  black  drop  every  sixth  hour ;  give  your  patient  a  Uttle  wine, 
and  have  recourse  to  the  oil  of  turpentine.  Here  the  value  of  this  re- 
medy is  very  great  indeed,  for  it  not  only  opens  the  bowels  (a  point  of 
considerable  importance  in  such  affections),  but  also  removes  tympanitis, 
and  exercises  a  powerful  influence  in  controlling  and  quieting  the 
nervous  system.  I  have  seen  persons'  lives  saved  by  a  few  doses  of  the 
oil  of  turpentine,  and  have  watched  its  tranquiUizing  effect  on  the  nerves 
with  pleasure  and  surprise.  The  folloAving  is  the  prescription  which  I 
use  : — 


134  CLINICAL  MEDICINE. 

R.  Olei  Terebinthini,  f3i. 
Olei  Ricini,  fSiss. 
Aquce,  f^i*     Misce,  fiat  haustus,  sexta  quaque  hora  sumendus. 

Under  certain  circumstances,  turpentine  is  likewise  useful  in 
intestinal  hemorrhage,  occurring  in  fever.  A  person  in  fever  gets 
increased  frequency  of  pulse,  heat  of  skin,  dry  tongue,  and,  about 
the  twelfth  day,  his  head  becomes  engaged,  his  countenance  flushed, 
eyes  suifused,  and  a  tendency  to  sensorial  derangement.  His 
bowels,  at  the  same  time,  are  affected,  and  tympanitis  appears.  Matters 
then  grow  worse,  he  begins  to  pass  blood,  and,  on  visiting  him, 
his  alarmed  relatives  show  you  quantities  of  thin  grumous  blood, 
which  he  has  discharged  from  his  bowels.  Now,  what  course  are 
you  to  pursue  in  this  case  ?  Stop  all  medicines  whatsoever,  and  let 
your  patient  alone.  Watch  the  progress  of  this  discharge,  and  you  will 
find  that  it  disappears  gradually,  and  when  this  occurrence  takes  place, 
never  do  any  thing.  As  in  fever,  a  patient  may  get  epistaxis,  and  it 
may  usher  in  a  favourable  crisis,  so,  in  like  manner,  he  may  have  a  cri- 
tical discharge  of  blood  from  the  bowels.  In  either  case,  you  are  not 
to  interfere  with  the  wise  provisions  of  nature,  or  to  give  any  thing 
which  may  produce  irritation,  or  cause  a  cessation  of  this  salutary  pro- 
cess. You  recollect  a  case  of  tliis  kind  in  the  hospital,  which  the  stu- 
dents requested  me  to  stop,  and  that  I  refused  to  do  so,  because  I  thought 
the  hemorrhage  critical.  But  it  may  happen,  that  this  sanguineous  flux 
may  go  on  so  far  as  to  threaten  great  danger.  This  is  certainly  an  oc- 
casional result,  for  I  have  seen  epistaxis  terminate  fatally.  Here  you 
must  interfere  to  avoid  a  greater  evil ;  and  it  is,  at  this  critical  period, 
that  the  internal  exhibition  of  oil  of  turpentine,  combined  with  opium, 
may  be  ventured  on ;  but  while  the  bleeding  continues  moderate,  and 
exhibits  no  threatening  indications,  and  is  accompanied  by  a  correspond- 
ing diminution  of  fever,  you  should  leave  the  matter  entirely  to  nature. 
You  perhaps  have  seen  a  patient  here,  who,  on  the  14th  day  of  fever, 
got  this  discharge  of  grumous  blood,  and  may  remember  that  we  gave 
nothing  but  a  Uttle  of  the  saturated  solution  of  carbonate  of  ammonia. 
Now,  if  we  had  given  this  patient  an  opiate,  we  should  have  repressed  a 
sanatory  effusion,  or,  if  we  had  given  him  a  purgative,  we  might  have 
precipitated  it  into  a  fatal  hemorrhage. 

I  shall  next  proceed  to  make  a  few  observations  upon  hiccup. 

"When  hiccup  occurs  in  typhus  fever,  it  is  generally  owing  to  a  con- 
gested state  of  the  mucous  membrane,  accompanied  by  flatulent  dis- 
tention of  the  stomach  and  bowels.  A  remarkable  case  of  this  sort  oc- 
curred to  Dr.  Ireland  and  myself,  in  which  a  corpulent  man,  labouring 
under  maculated  typhus,  hiccupped  during  several  days,  more   than 


I 


HICCUP  IN    FEVER.  135 

eighteen  hours  out  of  the  twenty-four,  as  was  ascertained  by  notes  kept 
by  his  sister,  who  carefully  watched  him. 

In  such  cases,  the  remedies  adapted  for  tympanitis  in  typhus  fever 
are  most  appropriate,  and  therefore  much  variety  of  treatment  is  re- 
quired. Thus,  when  hiccup  occurs  early  in  the  disease,  along  with 
much  thirst,  parched  tongue,  and  tender  epigastrium,  the  treatment 
ought  to  consist  of  leeches  to  that  part,  iced  water  in  small  (quantities, 
diete  ahsolue,  and  bland  aperient  injections.  But  when  it  comes  on  late 
in  the  disease,  we  must  have  recourse  to  stimulating  liniments  applied 
to  the  spine ;  blisters  to  the  epigastrium ;  and  if  the  bowels  are  at  the 
same  time  confined  and  distended,  oil  of  turpentine  internally,  or  by 
lavement,  while  the  strength  is  supported  by  wine  and  proper  nutri- 
ment. Here  the  oil  of  turpentine  is  best  given  in  doses  of  two  or  three 
drachms,  combined  with  castor  oil;  but  on  the  other  hand,  when 
diarrhoea  is  present,  together  with  tympanitis,  we  must  have  recourse  to 
acetate  of  lead,  as  before  recommended,  to  various  stimulants  in  small 
and  repeated  doses,  such  as  turpentine,  sether,  &c.,  combined  with  opium. 
In  fever,  hiccup  occasionally  occurs  without  any  obvious  derangement 
of  the  alimentary  canal  being  present,  and  without  our  being  able  to 
detect  any  cause  of  this  symptom.  Our  treatment  under  such  circum- 
stances must  be  empirical,  and  relief  will  be  frequently  obtained  by  the 
exliibition  of  some  substance  which  has  an  obvious  action  on  the  nervous 
system ;  but,  as  I  have  said,  our  treatment  must  be  empirical — ^in  one 
patient  we  may  find  success  attend  the  exhibition  of  an  alkali,  in  another, 
of  an  acid.  The  same  observation  applies  to  swallowing  of  ice,  or 
water  as  hot  it  can  be  drank,  to  the  various  narcotics  and  stimulants,  to 
musk,  camphor,  &c.  &c. 

Let  me  again  call  your  attention  to  another  circumstance  con- 
nected with  the  state  of  the  digestive  organs  in  fever,  which  I  inci- 
dentally mentioned  a  few  moments  since,  namely,  hemorrhage  from  the 
bowels.  I  have  seen  four  patients  in  whom  the  occurrence  of  hemor- 
rhage from  the  bowels  induced  death — in  all  the  fever  had  a  marked 
gastric  character,  and  the  passing  of  blood  was  at  first  unattended  by 
tenesmus,  pain  in  the  abdomen,  or  any  swelling  of  the  bowels  or 
tenderness  denoting  local  ailment  in  the  intestinal  canal.  The  bleeding 
continued  many  days,  the  stools  being  mostly  copious,  and  consisting 
either  altogether  of  black  grumous  clots  mixed  with  fluid  blood,  or  else 
of  blood  mixed  intimately  with  fecal  matter.  Sometimes  not  more  than 
one  or  two  evacuations  took  place  daily,  and  the  debility  not  being  pro- 
portioned to  the  quantity  of  blood  lost,  it  is  more  than  probable  that  in 
such  cases  the  bleeding  continued  into  the  bowels  in  much  greater  quan- 
tity than  the  blood  was  evacuated. 


136  CLINICAL   MEDICINE. 

In  all  these  cases  the  hemorrhagic — dicrotous,  pulse  (seepage  50)  pre- 
ceded the  discharge  of  blood. 

It  has  been  satisfactorily  proved  by  modern  investigations,  that  the 
dark-coloured  matter  similar  in  appearance  to  coffee-grounds,  which  is 
discharged  from  the  bowels  in  tliis  disease  and  yellow  fever,  consists  of 
the  coagulum  of  blood  broken  down  and  darkened  in  tint  by  the  acids 
of  the  intestinal  canal.  I  had  lately  an  opportunity  of  observing  a  fact 
strikingly  corroborative  of  this  explanation.  A  young  gentleman  la- 
bouring under  very  severe  fever,  with  violent  headache,  was  attended  by 
Sir  Philip  Crampton  and  me.  On  the  seventh  day  of  his  illness,  two 
leeches  were  applied  to  the  internal  surface  of  his  nostrils,  and  produced 
a  very  copious  flow  of  blood,  large  quantities  of  which  were  swallowed 
by  the  patient  during  his  sleep.  In  thirty-six  hours  after  the  bleeding 
had  ceased,  the  nurse-tender  became  very  much  alarmed  on  observing 
the  blackness  of  the  alvine  discharges.  She  told  the  family  that  it  was 
a  very  dangerous  symptom,  and  I  was  sent  for  in  great  haste.  I  need 
scarcely  add,  that  on  seeing  the  evacuation  of  so  large  a  quantity  of 
matter  resembhng  coffee-grounds,  the  true  explanation  of  the  occur- 
rence immediately  suggested  itseK,  and  enabled  me  to  dispel  the  alarm 
of  my  patienf  s  parents. 

When  blood  is  swaM.owed  by  a  person  in  health,  whose  digestive 
organs  are  vigorous,  it  never  forms  any  thing  hke  coffee-grounds  in  the 
large  intestines,  but  is  thoroughly  digested  and  absorbed  in  the  superior 
portion  of  the  ahmentary  canal. 


137 


LECTURE  XI. 


GENERAL    TREATMENT  OF  FEVER. EMETICS. PURGATIVES. BLEEDING. 

Having  spoken  at  some  length  respecting  epidemics^  one  only  fact 
occurs  to  me  in  addition  to  those  already  detailed.  It  by  no  means  fol- 
lows when  fever  has  a  decidedly  malignant  type,  that  other  acute  dis- 
eases which  prevail  at  the  same  time  should  exhibit  a  similar  tendency ; 
thus  measles  and  scarlatina  are  often  epidemic  simultaneously  with  fever, 
and  yet  each  of  the  three  may  present  a  different  type.  In  the  year 
1842  we  witnessed  a  very  widely  disseminated  epidemic  of  scarlatina, 
whose  character  was  most  malignant  and  fatal,  and  yet  fever  during 
that  period  was  unusually  mild  in  its  form,  while  measles  were  rife  and 
of  a  purely  inflammatory  character.  Here  then  was  a  year  during  which 
fever,  without  becoming  inflammatory,  ceased  to  be  typhus,  scarlatina 
assumed  a  typhoid  character,  and  measles  prevailed,  but  of  a  purely  in- 
flammatory type  !  This  statement,  for  the  accuracy  of  which  I  can 
vouch,  teaches  how  difficult  it  is  to  explain  the  causes  wliich  give  to 
epidemics  their  peculiar  complexion ;  indeed  for  several  years  scarlatina 
had  been  extremely  malignant,  and  during  the  same  period  measles  very 
benign ;  so  that  we  must  not  too  hastily  adopt  the  hypothesis  that  some 
general  cause  exists  capable  of  simultaneously  modifying  diseases  of  dif- 
ferent species — an  hypothesis  which  has  found  many  advocates,  among 
the  rest  Dr.  Watson,  who  says,  "  Sydenham  found  that  measles  of  an 
unusually  bad  kind  prevailed  in  London  in  the  years  1670  and  1674  ; 
the  very  same  years  in  which  small-pox  was  also  remarkably  malignant 
and  fatal.  This  illustrates  what  I  have  stated  before,  viz.,  that  the 
typhoid  tendencies  of  these  and  other  febrile  disorders  depend  less  up- 
on any  peculiar  virulence  in  their  exciting  causes,  than  upon  some 
change  previously  effected  in  the  human  body  by  the  silent  and  gradual 
influence  of  certain  predisposi7ig  causes""^ 

*  Lectures  on  the  Practice  of  Physic,  vol.  2,  p.  730.  Is-t  ed. 


138  CLINICAL   MEDICINE. 

I  have  already  observed,  that  it  is  not  my  intention  to  give  a  systema- 
tic account  of  the  practice  to  be  adopted  in  the  treatment  of  typhus. 
I  have  designedly  passed  over  many  important  points,  being  unwiUing 
to  trouble  you  with  any  observations  on  practical  matters  in  which  my 
opinions  coincide  with  the  latest  and  best  authorities.  I  shall  therefore 
touch  very  briefly  on  the  subject  of  emetics  in  fever,  as  the  rules  by 
which  the  administration  of  these  remedies  are  regulated  have  been  laid 
down  with  precision  by  many  modern  writers. 

1  am  not  in  the  habit  of  using  emetics  in  fever,  except  when  called 
in  at  the  very  commencement  of  the  disease.  Here  emetics  are  of 
great  value,  and  will  often  succeed  in  stopping  the  fever.  There  is  no 
way  in  which  you  would  be  more  likely  to  cut  short  an  attack  of  fever 
than  by  the  administration  of  an  emetic,  if  you  chance  to  see  the  patient 
when  the  fever  is  just  beginning.  I  speak  here  without  any  subter- 
fuge, and  without  grounding  my  opinions  on  the  results  of  doubtful  or 
merely  suspicious  cases.  I  speak  not  of  cases  of  bad  feverish  cold,  in 
which  the  symptoms,  at  the  commencement,  bear  a  very  strong  analogy 
to  those  which  usher  in  typhus ;  I  speak  of  cases  where  the  patient  gets 
rigors,  followed  by  the  usual  symptoms  of  feverish  excitement,  after  ex- 
posure to  contagion,  and  is  seen  on  the  evening  of  seizure. 

If  I  were  called  to  visit  a  patient  who  had  been  attacked  with  shiver- 
ing, headach,  quickness  of  pulse,  increased  temperature  of  skin,  and 
lassitude,  during  the  prevalence  of  an  epidemic,  or  after  exposure  to 
contagion,  and  happened  to  see  him  a  few  hours  after  the  attack,  I  should 
certainly  bleed  him,  and  administer  an  emetic :  and  I  think  he  would 
have  a  very  good  chance  of  escaping  the  disease.  I  think  the  exhibi- 
tion of  emetics  an  excellent  practice  in  the  commencement  of  fever, 
but  I  must  observe  that  the  period  for  their  exhibition  is  very  brief. 
After  the  lapse  of  twenty-four  or  thirfcy-six  hours  from  the  occurrence 
of  the  rigor,  they  will  not  succeed  in  cutting  short  the  fever.  A  few 
hours  make  a  vast  difference  in  the  chances,  and  after  the  lapse  of 
twenty-four  hours,  there  is,  generally  speaking,  very  little  hope  of  ex- 
tinguishing the  disease.  At  the  termination  of  that  period,  it  has  in 
most  cases  seized  hold  of  the  constitution  too  firmly  to  be  shaken  off  by 
an  emetic,  even  though  aided  by  bleeding,  but  for  the  first  few  hours 
after  seizure,  the  plan  I  have  mentioned  affords  you  a  reasonable  hope 
of  being  able  to  put  a  stop  to  the  mischief  at  once.  Army  surgeons, 
and  practitioners  who  have  opportunities  of  treating  incipient  disease, 
are  well  aware  of  the  truth  of  these  observations.  I  have  myself  vidt- 
nessed  many  cases  in  private  practice,  of  medical  men  and  students,  who 
had  been  attacked  with  symptoms  of  fever  after  exposure  to  contagion, 
and  who  escaped  by  taking  an  emetic  and  being  bled  in  proper  time. 


EMETICS    AT   THE    COMMENCEMENT    OF    FEVER.  139 

Let  me  here  read  for  you  a  few  observations  on  the  use  of  emetics  at 
the  commencement  of  fever,  which  appear  to  me  to  be  very  judicious: — 

"  When  the  opportunity  offers  of  administering  remedies  in  the  iSrst 
days  of  fever,  an  emetic  may  often  be  given  with  advantage,  especially 
where  the  type  of  the  fever  is  mild.  An  emetic  clears  the  stomach  of 
offending  matters  or  sordes,  which  may  be  either  undigested  ahment, 
bile,  tliickened  and  vitiated  mucus,  or  its  own  thin  acid  or  acrid  secre- 
tions. Besides  which,  an  emetic  has  the  additional  advantage  of 
determining  the  blood  to  the  surface,  and  in  tliis  way  relieving  the 
oppressed  state  of  internal  organs.  A  powerful  emetic  may  sometimes 
give  the  system  a  shock,  sufficient  to  alter  the  course  of  the  symptoms, 
and  even  to  cut  the  fever  short.  This  practice  however,  is  not  without 
its  dangers.  In  some  cases  it  determines  morbid  action  to  the  stomach, 
and  renders  that  organ  irritable  during  the  whole  course  of  the  fever. 
At  other  times  an  emetic  brings  on  local  inflammation  in  some  impor- 
tant viscus,  on  the  same  principle  that  it  forces  out  sweat.  As  a 
general  rule,  we  are  not  justified  in  giving  an  emetic,  unless  we  have 
reason  to  tliink  that  the  stomach  is  foul,  that  is,  goaded  with  acrid 
matters,  whether  formed  within  the  body,  or  received  into  it  from 
without.''' — Gregory's  Practice  of  Medicine ,  page  121.    Sixth  Edition. 

"  The  arrest  of  fever  may  he  also  successfully  attempted  during  the 
stage  of  invasion,  or  up  to  the  commencement  of  vascular  reaction  or 
excitement;  but  when  once  this  period  has  supervened,  the  fever  will 
run  a  regular  course,  although  it  will  often  be  much  shortened  by 
treatment.  Eevers,  I  believe,  caused  by  infection,  are  very  rarely 
arrested  after  reaction  is  estabhshed.  The  means  just  advised  for  the 
formative  stage  may  likewise  be  tried  in  tliat  of  invasion ;  but  much 
discrimination  is  requisite  in  the  choice  of  means.  Camphor,  ammonia, 
and  warm  diaphoretics  and  diluents,  sometimes  with  opium,  when  the 
head  is  not  affected ;  the  warm  bath,  the  vapour  or  heated  air  bath, 
and  frictions,  subsequently,  are  the  most  generally  appropriate.  In 
robust  persons,  and  where  terrestrial  emanations  have  been  the  chief 
cause,  a  warm  emetic  and  active  stomachic  purgatives  may  also  be 
exliibited;  but  they  should  more  rarely  be  ventured  upon  in  other 
circumstances,  for  the  reasons  just  assigned.  When  there  is  tenderness 
at  the  epigastrium,  with  other  signs  of  gastric  irritation  and  depression 
of  nervous  power,  instead  of  an  emetic  or  cathartic,  a  large  sinapism, 
or  a  warm  turpentine  epithem,  should  be  placed  upon  this  region,  and 
over  a  great  part  of  the  abdomen ;  or,  in  other  cases,  upon  the  inside 
of  the  tliighs,  but  neither  of  these  ought  to  be  resorted  to  if  reaction 
have  supervened,  nor  continued  after  it  has  come  on.'' — Copeland's 
Medical  Bictionary,  vol.  i.  page  921. 


140  CLINICAL   MEDICINE. 

Except  at  the  commencement,  then  I  am  not  an  advocate  for  the  use 
of  emetics  in  fever.  If  they  fail  in  checking  the  disease,  they  are  apt 
to  be  followed  by  considerable  debility  of  the  stomach  and  general  sys- 
tem— states  which  it  would  be  better  to  avoid,  where  the  patient  has  to 
run  through  the  course  of  a  long  and  exhausting  disease.  If  called  to 
a  case  of  fever  in  which  you  cannot  give  an  emetic,  there  are  two  or 
three  other  remedial  agents  you  may  employ  to  moderate  tlie  feverish 
excitement,  and  render  the  disease  milder  and  more  manageable  during 
its  progress.  One  of  these  is  Jameses  powder,  with  which  you  may 
combine  blue  pill  or  hydrargyrum  cum  creta,  if  necessary,  giving  two 
or  three  grains  of  each  every  third  or  fourth  hour,  according  to  circum- 
stances. Another  remedy,  which  many  are  in  the  habit  of  using,  par- 
ticularly where  the  fever  is  accompanied  with  symptoms  of  inflammatory 
excitement,  is  a  weak  solution  of  tartar  emetic.  Two  grains  of  tartar 
emetic  may  be  dissolved  in  a  pint  of  barley  water,  and  of  this  mixture 
a  table-spoonful  may  be  taken  every  second  hour.  These  are  good  and 
useful  remedies  in  the  first  stages  of  fever ;  they  moderate  the  feverish 
excitement,  act  ge^tlj  on  the  bowels,  and  produce  more  or  less  diapho- 
resis. 

It  most  commonly  happens  that  the  physician  is  not  called  to  see  a 
case  of  fever  until  forty-eight  hours,  or  perhaps  three  or  four  days,  have 
elapsed,  from  the  period  of  seizure.  In  this  climate,  feverish  colds  are 
extremely  frequent ;  and  as  their  symptoms  bear  considerable  resem- 
blance to  those  of  incipient  fever,  and  very  few  are  capable  of  making 
a  distinction  between  them  for  some  time,  a  person  attacked  with  fever 
usually  regards  it,  at  the  first  onset,  as  the  result  of  cold,  and  expects 
to  be  able  to  alleviate  or  remove  it  in  a  few  days  by  bathing  his  feet 
and  taking  a  warm  drink  at  night,  with,  perhaps,  some  opening  medi- 
cine on  the  following  morning.  The  usual  period,  however,  at  which 
the  feverish  cold  had  been  accustomed  to  decline,  passes  over  \vithout 
the  expected  amendment,  the  patient  feels  himself  weaker  and  worse, 
the  conviction  is  brought  home  to  him  that  his  disease  is  something 
more  than  an  ordinary  cold,  and  he  sends  for  a  physician  about  the 
third  or  fourth  day.  Now  at  this  period,  I  beheve,  you  must  be  con- 
tent to  let  the  fever  run  its  course, ;  for  it  has  taken  root  too  deep  to 
be  expelled  by  a  coup  de  main,  and  yet  many  persons  seem  to  think 
they  can  still  succeed  by  what  they  term  bold  and  decided  treatment. 
The  mode  which  they  generally  adopt  is,  first,  to  administer  an  emetic, 
and  then  to  have  recourse  to  copious  and  continued  purgation.  This 
leads  me  to  say  a  few  words  on  the  use  of  purgatives  in  fever. 

The  abuse  of  purgatives,  particularly  in  the  first  stage  of  fever,  con- 
tinues, I  am  sorry  to  state,  even  to  the  present  day,  a  blot  on  the  clia- 


THE    USE    OF    PURGATIVES    IN    FEVER  141 

racter  of  practical  medicine.  Large  doses  of  calomel,  and  vegetable 
purgatives,  in  the  form  of  pill  or  bolus,  followed  by  draughts  composed 
of  infusion  of  senna,  Epsom  salts,  and  electuary  of  scammony,  form 
the  chief  part  of  the  treatment  in  fever  with  too  many  practitioners. 
I  know  well  that  this  is  a  mode  of  proceeding  too  commonly  employed, 
and  I  have  frequently  heard  those  who  adopt  it,  when  questioned  as  to 
the  remedies  they  have  used,  declare,  with  much  self-satisfaction,  that 
the  patient's  bowels  have  been  well  cleared  out.  This,  I  believe,  is  a 
very  common  mode  of  treating  fever  in  the  incipient  stage ;  and  though 
there  can  be  no  objection  to  the  administration  of  a  purgative,  as  a  cau- 
tionary measure,  particularly  where  an  accumulation  of  fecal  matter  in 
the  bowels  is  suspected,  I  must  confess  that  my  experience  does  not 
autliorise  me  to  say,  that  fever  can  be  either  checked  or  mitigated  by 
continued  purgation. 

If  active  purgation  does  not  check  fever  in  the  commencement,  what 
benefit,  then,  can  be  expected  from  it  ?  People  will  tell  you  that  fuU 
purging  must  act  beneficially  in  two  ways ;  by  unloading  the  bowels, 
and  by  evacuating  the  general  system.  "With  regard,  to  evacuating  the 
bowels,  I  think  it  can  be  done  well  and  sufficiently  by  the  use  of  mild 
aperients.  It  is  seldom  necessary  to  give  active  purgatives,  and  we 
never  have  occasion  to  continue  their  employment  from  day  to  day. 
The  bowels,  I  repeat,  can  be  sufficiently  unloaded  by  the  exhibition  of 
mild  aperients  and  enemata,  and  even  these  will  seldom  be  required 
more  than  once  or  twice  in  the  commencement,  and  occasionally  during 
the  course  of  the  disease.  The  second  question  (in  reference  to  the 
use  of  purgatives  as  general  evacuants)  is,  whether  it  is  prudent  or  safe 
to  act  antiphlogistically  on  the  system  through  the  medium  of  the  in- 
testinal canal,  during  the  first. stage  of  fever?  My  opinion  is,  that  it 
is  not.  I  grant  that  the  administration  of  active  purgatives  is  followed 
by  a  copious  evacuation  of  the  fluid  secretions  of  the  intestinal  canal, 
and  that  in  this  way  you  deplete  the  system  to  a  very  considerable  ex- 
tent. Admitting  all  this,  and,  moreover,  that  depletion  is  required, 
still  I  am  of  opinion  that  tliis  is  not  the  best  way  of  effecting  it,  and 
shall  always  give  a  preference  to  the  action  of  other  remedies.  I  prefer 
the  action  of  James's  powder,  or  tartar  emetic,  or  nitrate  of  potash,  or 
leeches,  or,  in  fact,  any  remedy  which  will  act  with  less  risk  of  subse- 
sequent  mischief. 

I  have  observed  that  the  abuse  of  active  purgatives  in  the  com- 
mencement of  fever — nay,  even  the  exhibition  of  cathartics  two  or 
three  times,  in  the  beginning  of  fever,  in  persons  with  irritable  bow^els, 
is  very  apt  to  induce  excitement  of  the  gastro-intestinal  mucous 
surface,  giving  rise  to  early  and  profuse  diarrhoea,  tympanitis  of  a  bad 


142  CLINICAL   MEDICINE. 

and  unmanageable  character,  and  not  unfrequently  to  disease  of  the 
mucous  coat  of  the  digestive  canal.  Great  tenderness  of  the  belly, 
meteorism,  and  exhausting  diarrhoea,  are  the  general  consequences  of 
early  and  continued  purgation.  In  private  practice  I  can  generally 
tell,  by  examining  the  patient's  belly,  whether  he  has  been  actively 
purged  in  the  commencement  of  the  disease  or  not.  I  invite  you  to 
study  the  cases  that  come  before  you  in  hospital,  with  reference  to  this 
point ;  I  think  you  will  find  in  most  instances,  that  the  patients  who 
have  escaped  active  purgation  before  admission,  wdll  get  through  the 
disease  with  little  or  no  tympanitis.  The  physician  who  merely  employs 
mild  aperients  and  enemata — ^who  does  not  use  active  purgatives  from 
day  to  day,  as  is  too  often  done — will  not  have  his  plans  of  treatment 
embarrassed  by  the  occurrence  of  dangerous  tympanitis,  or  obstinate 
and  debilitating  diarrhoea;  nor  will  he  have  the  melancholy  prospect 
before  him  of  having  an  inflammatory  affection  of  the  gastro-intestinal 
mucous  membrane  to  treat,  at  a  period  when  neither  the  condition  nor 
the  constitution  of  the  patient  will  bear  any  thing  like  antiphlogistic 
measures. 

As  to  purging  in  general,  the  idea  of  curing  fever  by  it  is  quite  ab- 
surd. In  fever,  all  the  secretions  are  affected,  and  it  would  be  idle  to 
think  of  altering  and  improving  all  by  acting  on  the  bowels.  Take 
the  skin,  for  example.  Consider  what  a  departure  there  is  from  the 
normal  state ;  observe  the  quantities  of  moisture  which  exude  from  it 
without  any  apparent  cause,  or  its  equally  inexplicable  dryness.  Its 
odour,  its  feel,  its  nervous  and  vascular  conditions,  are  all  more  or 
less  altered.  Take  the  lungs,  in  the  next  place.  There  is  generally 
some  change  in  the  smell  of  the  patient's  breath ;  there  is  some  change 
also  in  the  quantity  of  the  pulmonary  exhalation ;  there  is  an  alteration 
in  the  rate  and  mode  of  respiration ;  and  I  have  ascertained,  by  expe- 
riment, that  a  person  in  fever  does  not  consume  as  much  oxygen,  or 
give  out  as  much  carbon,  as  he  would  in  a  state  of  health.  Observe 
the  functions  of  the  brain,  or  those  of  the  liver  or  kidneys,  and  see 
how  much  they  have  departed  from  the  normal  state.  Every  secretion, 
every  function,  is  more  or  less  deranged,  and  will  remain  so  as  long  as 
the  fever  lasts.  You  have  no  right  to  think  that  you  will  be  able  to 
restore  the  healthy  state  of  the  stomach  and  bowels  any  more  than  that 
of  any  other  organ.  The  secretions  of  the  lungs,  liver,  pancreas,  kid- 
neys, stomach,  and  skin,  are  all  deranged,  or  more  or  less  suppressed, 
and  will  not  be  restored  to  a  healthy  state  until  a  crisis  comes  on,  or 
the  disease  begins  to  decline. 

As  long  as  the  belly  is  soft  and  fallen,  and  where  the  bowels  have 
been  sufficiently  opened  in  the  commencement  of  the  disease,  I  do  not 


USE  OF  PURGATIVES  IN  FEVER.  14^ 

feel  the  least  anxiety  if  the  patient  remains  without  having  a  stool  for 
two  or  three  days.  I  have^  on  some  occasions  in  private  practice,  been 
induced  to  consent  to  the  exhibition  of  a  purgative  where  I  did  not 
think  it  required ;  and  have  seldom  done  so  without  regretting  it  after- 
wards. The  patient  has  been  going  on  well,  the  belly  soft  and  fallen, 
no  tenderness  present,  and  no  distinct  evidence  of  fecal  accumulation. 
All  this  I  have  pointed  out  to  the  practitioners  in  attendance  with  me, 
but  to  no  purpose.  They  woidd  generally  observe  in  reply,  "  Oh  !  tliis 
may  be  all  true ;  but  you  see  the  patient  has  had  no  stool  for  the  last 
thirty-six  hours,  and  it  would  be  quite  wrong  to  let  liim  go  on  in  this 
way  any  longer/'  Indeed,  you  will  frequently  meet  with  cases  in  which 
you  should  exercise  much  caution  in  the  administration  even  of  ene- 
mata.  An  illustration  of  this  remark  occurred  to  me  lately  in  practice. 
In  a  case  of  fever  in  which  the  patient's  friends  were  importunate  as  to 
the  necessity  of  opening  the  bowels,  the  ordinary  purgative  injection 
was  prescribed.  It  proved  too  active,  and  produced  much  irritation  of 
the  bowels,  giving  rise  to  an  increased  secretion  of  gas  into  the  intes- 
tines, and  a  considerable  degree  of  temporary  tympanitis. 

You  will  be  guided,  therefore,  in  the  administration  of  purgatives, 
not  by  the  rule  of  those  who  are  dissatisfied  with  less  than  two  or  three 
motions  in  the  day,  but  by  the  circumstances  and  exigencies  of  the  case ; 
and  you  wiU  be  cautious  in  giving  purgatives,  except  where  you  have 
good  reasons  to  conclude  that  there  is  an  accumulation  of  feces.  In 
this  way  you  will  avoid  tympanitis,  diarrhoea,  and  inflammatory  afi'ections 
of  the  bowels ;  symptoms  which  always  give  great  annoyance  to  a  prac- 
titioner, and  tend  greatly  to  embarrass  liis  practice  in  the  treatment  of 
all  fevers  of  a  typhoid  character. 

So  far  concerning  the  administration  of  purgatives  as  a  cure  for  fever, 
or  as  a  means  of  diminisliing  its  violence.  You  perceive  that  I  think 
their  employment  more  than  questionable,  and  in  this  particular  am 
consequently  at  issue  with  Hamilton,  and  a  great  number  of  writers. 
There  are,  however,  circumstances  which  may  arise  during  the  course  of 
typhus,  and  may  require  a  free  use  of  purgative  medicines ;  we  are 
then  forced  to  have  recourse  to  purgatives,  not  in  the  hope  of  curing 
the  fever  itself,  but  for  the  purpose  of  removing  or  alleviating  certain 
superadded  symptoms. 

It  may  be  well  to  mention  some  of  the  cliief  of  these  symptoms. 
One  of  the  most  common  is  determination  of  blood  to  the  head,  pro- 
ducing delirium,  headache,  &c.  In  many  examples  of  this  nature,  occur- 
ring at  an  early  period  of  typhus,  purgatives  of  a  very  active  nature 
are  amongst  our  most  efficacious  remedies.  Nay,  even  in  the  advanced 
stages  of  fever,  dehrium  and  determination  to  the  head  are  seldom  re- 


144  CLINICAL  MEDICINE. 

lieved  by  tartar  emetic^  unless  it  produces  very  copious^  yellow^  watery 
stools.  Many  patients  become  uneasy  and  restless  at  night,  in  the  latter 
periods  of  fever,  in  consequence  of  insufficient  evacuations  from  the 
bowels ;  whenever,  therefore,  restlessness  or  sleeplessness  supervene  un- 
expectedly, and  that  the  bowels  are  confined,  the  occurence  of  these 
symptoms  calls  for  aperients,  even  though  the  belly  be  not  very  full  and 
tumid.  Preternatural  fulness  of  the  belly  and  tympanitis,  often  de- 
mand purgatives  at  any  period  of  the  disease. 

In  some  cases,  when  a  troublesome  diarrhoea  has  yielded  to  astringents, 
a  very  obstinate  and  long-continued  state  of  constipation  comes  on, 
apparently  connected  with  impaired  muscular  power  of  the  intestinal 
tube.  At  first,  the  confinement  of  the  bowels  produces  no  uneasiness 
on  the  part  of  the  medical  attendant,  inasmuch  as  it  is  unattended  by 
any  fulness  or  tension  of  the  abdomen,  and  the  patient  may,  in  other 
respects,  appear  to  be  doing  well.  After  some  days,  however,  it  is 
judged  prudent  to  excite  alvine  evacuations,  which  is  attempted 
cautiously,  for  the  practitioner  bears  in  mind  the  violence  of  the  pre- 
vious diarrhoea.  He  therefore  chooses  mild  purgatives  at  first,  and 
next  day,  finding  them  ineffectual,  he  ventures  on  the  exhibition  of 
more  active  medicines,  and  orders  a  frequent  repetition  of  injections. 
Even  these  steps  fail,  and  constipation  continues  for  several  days  after 
the  efforts  to  remove  it  have  been  commenced.  This  is  a  juncture  full 
of  difficulty.  In  such  cases,  much  caution  must  be  used  in  employing 
active  cathartics,  and  great  care  should  be  taken  to  remove  any  hardened 
feces  which  may  be  present  in  the  rectum  or  sigmoid  flexure  of  the  co- 
lon. This  must  be  done  partly  by  the  finger,  or  by  means  of  an  appro- 
priate scoop,  as,  for  instance,  a  marrow-spoon,  and  by  injections  of  soap 
and  water.  When  no  such  mechanical  obstructions  exist,  to  account 
for  the  failure  of  the  cathartics,  we  must  proceed  cautiously,  and  not 
rashly  accumulate  medicines  of  this  description  in  the  stomach  and 
bowels  of  the  patient. 

Yery  active  purgatives,  tliough  they  fail  to  stimulate  the  paralysed 
bowels  so  as  to  evacuate  their  contents,  may  yet  irritate  the  intestinal 
mucous  membrane,  and  cause  destructive  inflammation.  Tor  this  rea- 
son, where  moderate  doses  of  colocynth,  gamboge,  jalap,  scammony, 
rhubarb,  &c.,  have  failed,  they  must  not  be  repeated ;  neither,  except  in 
desperate  cases,  ought  we  to  administer  croton  oil  internally.  The 
neutral  salts,  senna,  magnesia,  and,  above  all,  castor  oil,  given  combined 
with  oil  of  turpentine,  or  uncombined  and  very  frequently  repeated, 
must  be  our  chief  internal  medicines.  In  some  cases,  the  compound 
decoction  of  aloes,  with  small  doses  of  sulphate  of  magnesia,  will  suc- 
ceed in  exciting  the  paralysed  bowels  to  action,  where  other   and  more 


/ 


BLEEDING  IN  FEVEK.  145 

powerful  purgatives  have  failed.  Injections  should  be  perseveringly 
repeated^  and  varied  both  in  quality  and  quantity ;  and  they  should  be 
always  thrown  as  far  as  possible  into  the  bowel^  by  means  of  a  flexible 
tube  and  Read's  syringe.  When  they  are  retained^  and  excite  swelhng 
of  the  belly,  as  too  frequently  happens  in  these  cases,  we  must  desist 
from  their  use. 

This  obstinate  state  of  constipation  may  be  supposed  to  depend  on  a 
degree  of  paralysis  of  the  bowels ;  for  usually  in  such  cases  an  evident 
paralysis  affects  the  bladder,  causing  retention,  or  its  sphincters,  giving 
rise  to  an  involuntary  dribbling  of  urine. 

On  the  subject  of  bleeding  in  fever,  I  have  but  very  few  remarks  to 
offer.  In  the  first  place,  with  respect  to  the  power  which  venesection 
possesses  of  checking  fever,  it  may  be  observed,  that  there  can  be  no 
doubt  that  it  has  frequently  been  found  capable  of  effecting  this  purpose, 
particularly  where  it  has  been  properly  employed,  and  in  conjunction 
with  other  means.  I  speak  here  wdth  reference  to  cases  in  which  bleed- 
ing has  been  used  under  favourable  circumstances,  and  very  soon  after 
seizure — as  in  students,  medical  practitioners,  hospital  attendants, 
soldiers,  and  seamen.  In  such  persons,  and  others  where  circumstances 
have  been  equally  favourable,  there  is  no  doubt  that  venesection  has 
frequently  succeeded  in  cutting  short  fever ;  and  if  called  to  a  case  of 
typhus  within  the  first  ten  or  twelve  hours  after  seizure,  I  should  have 
no  hesitation  in  having  recourse  at  once  to  venesection,  followed  by  an 
emetic ;  and  my  own  experience  convinces  me  that  I  should  afford  my 
patient  a  very  good  chance  of  escaping  the  disease.  I  have  on  several 
occasions  succeeded  in  arresting  the  progress  of  fever  by  these  means ; 
and  the  records  of  naval  and  military  practice  furnish  many  proofs  in 
corroboration  of  my  statements.  I  have  also  the  authority  of  Dr. 
Cheyne  (whose  experience  on  every  point  connected  with  fever  was  im- 
mense) in  favour  of  the  efficacy  of  bleeding  in  commencing  fever,  as 
a  mode  of  treatment  which  has  frequently  proved  successful  in  his  hands. 
But  it  is  only  in  the  very  commencement,  and  during  the  stage  of  rigor, 
that  you  can  hope  to  derive  any  advantage  from  venesection  in  cutting 
short  an  attack  of  fever.  I  do  not  mean  to  say  that  you  have  in  typhus, 
as  in  intermittent  fever,  distinct  rigors,  lasting  each  for  half  an  hour,  or 
even  longer ;  by  the  stage  of  rigor  in  typhus,  I  mean  to  designate  the 
period  of  formation,  during  which  the  patient  complains  of  recurrent 
chills,  although  his  skin  feels  hot  to  the  touch  when  examined  by  an- 
other person.  This  stage  lasts  generally  from  twelve  to  twenty-four,  and 
in  a  few  cases,  to  thirty-six  hours  ;  and  it  is  only  during  this  stage  that 
you  have  a  chance  of  extinguishing  the  fever  at  once,  by  the  abstraction 
of  blood  from  the  system. 

VOL.  I  *  10 


146  CLINICAL   MEDICINE. 

You  may  also  have  recourse  to  venesection  within  the  first  day  or 
two,  for  the  purpose,  not  of  arresting  fever  at  once,  but  of  lowering 
inordinate  vascular  action,  in  persons  of  a  robust  habit,  and  where  the 
fever  sets  in  with  violent  headache,  great  heat  of  skin,  and  a  firm 
bounding  pulse.  We  do  not,  however,  at  present  meet  with  many  such 
cases,  nor  are  we  often  called  in  at  a  period  when  venesection  might  be 
advantageously  practised.  The  physician  seldom  sees  a  case  of  fever 
until  the  third  or  fourth  day,  and  then  it  is  too  late  to  think  of  general 
depletion  by  the  lancet.  This  explains  why  venesection  is  so  seldom 
employed  in  typhus  in  our  hospitals. 

Moreover,  in  entering  on  the  treatment  of  any  case  of  fever,  you 
should  bear  in  mind  the  nature  of  the  prevailing  epidemic,  and  be 
careful  how  you  proceed  with  respect  to  bleeding;  and  if  you  take 
away  blood,  do  not  go  so  far  as  you  would  if  treating  a  case  of  fever 
under  different  circumstances,  and  of  a  genuine  inflammatory  character. 
I  know  that  many  persons  have  asserted  that  you  can  bleed  in  all  cases 
of  fever,  no  matter  what  the  state  of  debility  may  be ;  because  this,  they 
say,  is  only  apparent,  and  depends  upon  congestion  and  oppression  of 
vascular  action.  I  do  not  know  how  far  this  doctrine  may  be  applicable 
to  former  epidemics,  but  in  the  recent  epidemics  of  fever  we  have  had 
it  certainly  does  not  hold  good ;  and  no  man  in  his  senses  would  think 
of  adopting  it  as  a  guide  for  his  practice.  I  have  seen  some  of  the 
most  intense,  dangerous,  and  protracted  cases  of  fever,  commence 
without  any  appreciable  increase  of  vascular  action,  with  a  soft  slow 
pulse,  a  cool  skin,  no  appearance  of  congestion  of  any  internal  organ ; 
in  fact,  without  any  symptom  which  would,  even  in  the  youngest  and 
most  robust  habits,  call  for  the  use  of  the  lancet. 

Increased  vascular  action,  and  this  you  should  always  bear  in  mind, 
is  not  in  itself  a  proof  of  an  inflammatory  diathesis  in  fever,  but  rather 
one  of  a  set  of  symptoms  produced  by  the  same  morbid  cause.  The 
heat  of  skin  and  rapidity  of  pulse  are,  just  like  the  debility,  products  of 
the  same  morbid  cause,  aud  not  the  results  of  inflammation.  You 
should  also  recollect  that  in  fever,  as  well  as  in  other  diseases  in  which 
the  nervous  system  is  greatly  deranged,  the  pulse  is  not  unfrequently  a 
very  deceptive  guide.  In  many  cases  of  fever,  where  the  patient 
happens  to  be  of  an  irritable  habit,  the  pulse  exhibits  a  degree  of  thrill 
and  apparent  hardness,  which  might  lead  an  inexperienced  or  inob- 
servant practitioner  into  serious  errors.  I  do  not  mean  to  say  that  an 
inexperienced  finger  will  not  be  able  to  distinguish  a  pulse  of  this  kind 
from  one  of  genuine  hardness,  but  I  know  that  many  persons  have  been 
misled  by  it,  and  I  warn  you  against  the  danger. 

Again,  never  use  the  lancet  when  there  is  any,  even  the  slightest. 


BLEEDING    IN    FEVEIl.  147 

appearance  of  macu]a3,  no  matter  how  intense  the  headache,  heat  of 
skin,  or  signs  of  general  vascular  action,  may  be.  I  have  seen  some 
cases  in  which  the  lancet  was  used  during  the  presence  of  maculae,  and 
I  have  seen  its  employment  followed  by  the  most  lamentable  conse- 
quences. You  should,  therefore,  never  omit  to  examine  the  skin,  for 
circumstances  might  occur  which  would  authorise  a  moderate  use  of  the 
lancet,  provided  there  was  no  sign  of  maculse  present.  Formerly 
persons  were  very  much  in  the  habit  of  employing  arteriotomy  when 
the  headache  and  delirium  were  violent,  regardless  of  the  period  or 
stage  of  fever ;  and  nothing  was  more  common  than  to  see  a  physician 
ordering  the  temporal  artery  to  be  opened  on  the  eighth,  ninth,  or  even 
tenth  day.  This  was  very  much  the  practice  during  the  time  when  the 
doctrine  of  typhus  being  the  result  of  inflammation  of  the  brain  pre- 
vailed in  this  country  and  England,  and  a  very  unsuccessful  practice  it 
was.  You  perceive  we  seldom  have  recourse  to  arteriotomy  here ;  it 
may  be  occasionally  necessary,  and  when  it  is,  we  employ  it ;  but  as  a 
genera]  practice  it  does  not  appear  entitled  to  any  merit,  nor  can  we 
give  it  our  recommendation. 

The  examples  which  you  have  seen  in  hospital  show  you  that  local 
inflammation  arises,  generally  speaking,  at  a  period  when  general  bleed- 
ing is  no  longer  admissible.  I  shall  speak  hereafter  of  the  mode  in 
which  leeches  are  to  be  applied  to  the  head,  with  the  view  of  relieving 
headache  and  cerebral  congestion ;  it  is  not  necessary  that  I  should  say 
any  thing  respecting  their  application  to  the  epigastrium,  or  abdomen, 
for  the  reUef  of  gastro-intestinal  symptoms  in  the  beginning  of  fever, 
as  there  is  very  little  chance  of  your  doing  any  mischief,  even  by  the 
free  use  of  leeches,  at  this  period  :  it  only  remains  for  me  to  make  a  few 
remarks  on  the  use  of  leeches  and  cupping-glasses,  in  the  more  ad- 
vanced stages  of  the  disease. 

Well ;  your  patient,  suppose  about  the  ninth  or  tenth  day,  gets  pain 
in  his  side,  cough,  and  increased  frequency  of  respiration,  and,  on 
examination,  you  find  sufficient  evidence  of  the  existence  of  pneumonia. 
Or  he  complains  of -abdominal  symptoms,  aud  you  have  strong  reasons 
to  think  that  hepatitis  or  enteritis  is  present.  Here  you  will  have 
recourse  to  leeches  or  cupping,  according  to  the  circumstances  of  the 
case.  An  attack  of  pneumonia,  coming  on  in  fever,  frequently  acts  as 
a  stimulus  to  the  economy;  the  collapse  of  fever  disappears  more  or 
less,  and  the  pulse  becomes  more  firm  and  resisting.  This  is  a  fortu- 
nate occurrence,  for  under  such  circumstances  the  patient  is  better  able 
to  bear  depletion,  and  you  may  proceed  at  once  to  apply  cupping  glasses 
or  leeches  to  his  chest,  regulating  the  quantity  of  blood  .you  abstract, 
not  only  with  reference  to  his  present  symptoms,  but  also  to  his  future 


148  CLINICAL   MEDICINE. 

condition.  Bat  it  sometimes  happens  that  pneumonia  occurs  at  a  later 
period  of  the  disease,  and  when  you  cannot  use  cupping-glasses,  or  even 
leeches,  to  any  great  extent.  In  such  cases,  (and  the  same  remark  will 
apply  to  enteritis,  or  any  other  inflammation  occurring  in  the  advanced 
stage  of  fever,)  you  should  leech  with  great  caution ;  begin  with  four  or 
six  at  a  time,  and  when  they  drop  ofi*,  cover  the  leech-bites  with  a  cup- 
ping-glass. In  this  way  you  will  know  pretty  nearly  the  exact  quantity 
of  blood  which  the  patient  has  lost,  and  you  can  arrest  it  with  less 
difficulty  afterwards.  You  can  then  have  recourse  to  calomel  and 
opium,  or  tartar  emetic,  according  to  circumstances.  Leech  as  far  as 
you  can,  and  then  have  recourse  to  immediate  blistering,  and  such  other 
means  as  the  exigencies  of  the  case  may  demand. 

You  may  leech,  then,  freely,  and  without  any  particular  caution, 
in  the  commencement  of  fever,  whether  it  be  for  cerebral,  or  for  thoracic, 
or  abdominal  symptoms ;  but  as  the  fever  advances,  you  must  exercise 
more  discrimination  and  care,  both  as  to  the  number  of  leeches  you 
apply,  and  the  time  you  allow  them  to  bleed.  In  applying  leeches  to 
the  head,  I  would  advise  you  not  to  put  them  on  both  temples,  or 
behind  both  ears  at  once,  as  this  is  awkward,  and  prevents  the  patient 
from  lying  on  either  side.  You  may  also,  in  cases  of  cerebral  irritation, 
apply  them  to  the  nostrils  or  septum  narium ;  in  this  way  you  will  be 
able  to  get  away  a  large  quantity  of  blood  by  means  of  very  few  leeches, 
for  one  or  two  at  a  time  will  be  sufficient.  In  leeching  the  chest  and 
abdomen  in  particular,  I  advise  you  never  to  have  recourse  to  fomen- 
tations with  the  view  of  getting  more  blood  from  the  leech-bites.  Fo- 
mentations are  too  often  a  source  of  fresh  mischief  in  cases  of  this  kind, 
leading  to  exposure  of  the  patient  to  cold,  and  to  the  annoyance  of 
having  his  Hnen  and  bedding  kept  wet  for  hours  together.  Always 
give  directions  to  have  cupping-glasses,  or  hot  dry  flannel  clothes, 
applied  as  soon  as  the  leeches  drop  ofi",  and  you  will  have  less  difficulty 
in  arresting  its  flow  afterwards,  a  point  of  some  importance  in  cases 
where  the  loss  of  even  a  trifling  quantity  of  blood  is  often  of  great 
moment,  and  likely  to  have  a  very  powerful  effect  on  the  state  of  the 
patient. 


149 


LECTURE  XII. 


THE    USE    AND    EMPLOYMENT    OF    BLISTERS    IN    FEVER. 

Blisters  are  employed  in  a  variety  of  diseases,  but  are  followed  by 
very  different  physiological  effects^  and  capable  of  serving  very  different 
purposes,  according  to  their  mode  of  application.  In  fever  they  are 
generally  employed  either  as  stimulants,  or  as  evacuants  and  deriva- 
tives. As  stimulants,  they  may  be  used  with  the  intention  of  rousing 
the  depressed  energies  of  the  system  in  general,  by  their  action  on  the 
nervous  and  circulating  systems,  or  of  stimulating  the  torpid  functions 
of  some  particular  part  or  organ.  With  this  object  in  view,  they  are 
applied  as  flying  blisters — that  is  to  say,  for  a  space  of  time  not  exceed- 
ing two  or  three  hours,  and  solely  with  the  intention  of  producing  a 
stimulant  effect.  You  have  seen  some  cases  of  fever  in  our  wards,  in 
which  the  powers  of  life  were  greatly  depressed,  the  extremities  cool, 
the  action  of  the  heart  feeble,  the  pulse  weak,  respiration  short  and 
imperfectly  performed,  and  a  tendency  to  faintness  and  sinking ;  and 
you  have  observed  that  in  such  cases  we  derived  great  benefit  from  the 
application  of  flying  blisters  over  the  region  of  the  heart,  the  epigas- 
trium, chest,  and  inside  of  the  legs  and  thighs.  We  applied  our  blis- 
ters in  these  situations,  left  them  on  for  three  or  four  hours,  and  then 
removed  them ;  and  you  have  seen  them,  when  employed  in  this  way, 
succeed  in  rousing  the  vital  energies,  the  depressed  action  of  the  heart 
and  capillary  system,  and  the  flagging  state  of  the  respiratory  action,  as 
shown  by  the  increased  strength  of  the  pulse,  the  more  general  diffusion 
of  heat,  and  the  renewed  play  of  the  various  functions. 

In  such  cases,  where  the  stimulant  effect  alone  is  required,  it  would 
be  wrong  to  leave  the  blisters  on  longer  than  two  or  three  hours ;  it 
will  be  quite  sufficient  if  they  prove  merely  rubefacient,  or,  at  most, 
vesicate  so  slightly  as  to  give  to  the  blistered  surface  the  appearance  of 
a  miliary  eruption.  Here  you  have  all  the  stimulant  effects  of  blister- 
ing, but  not  followed  by  their  debilitating  consequences.     You  are 


150 


CLINICAL   MEDICINE. 


aware  that  blisters  applied  in  the  ordinary  way  have  a  twofold  effect ; 
they  first  rouse,  and  then  depress ;  acting  primarily  as  stimulants,  and 
secondarily  as  evacuants.  They  first  act  as  stimulants,  producing  pain, 
heat,  and  redness  of  the  part ;  after  a  few  hours  these  symptoms  di- 
minish, and  are  followed  by  an  effusion  of  serum — in  fact,  a  quantity 
of  white  blood  is  abstracted  from  the  cutaneous  capillaries,  and  in  this 
way  an  evacuation  is  produced,  calculated  to  diminish  any  accidental 
congestion  in  neighbouring  parts.  The  capillaries,  by  means  of  their 
increased  action,  draw  a  quantity  of  white  blood  to  the  part ;  and  in 
saying  this,  I  think  I  am  only  using  a  perfectly  physiological  expression 
for  the  quantity  of  circulating  fluid  in  any  part  of  the  body  must  de- 
pend on  the  vital  action  of  the  capillary  vessels  of  that  part.  It  is  to 
the  peculiar  state  of  the  capillary  vessels,  as  I  have  proved  in  a  previous 
lecture,  that  the  quantity  of  blood  in  any  part  is  to  be  referred,  and 
not  to  the  force  or  frequency  of  the  heart's  action.  It  is  by  means  of 
changes  produced  in  them  that  the  phenomena  of  active  congestion 
and  inflammation  are  produced  ;  the  capillaries  of  the  affected  part 
enlarge,  increase  in  number,  and  multiply;  and  those  which  were 
invisible  become  visible.  These  phenomena  have  been  falsely  attri- 
buted by  Hastings  and  others  to  debility  and  impaired  action  of  the 
capillaries. 

Blisters,  then,  produce  first  increased  action  of  a  part,  and  after- 
wards act  as  evacuants.  They  also  stimulate  the  system  generally ;  but 
if  left  on  until  full  vesication  is  produced,  they  act  as  evacuants  and 
depletives,  and  lower  the  general  tone  of  the  economy.  I  have  fre- 
quently observed  this  succession  of  events  in  chronic  cases,  in  which 
it  was  found  necessary  to  bUster  repeatedly  during  the  course  of  the 
disease.  The  patients  generally  told  me  that  they  felt  better  and  lighter 
on  the  day  on  which  the  blister  was  applied,  but  on  the  next  day  they 
usually  felt  weaker  and  more  depressed ;  and  tliis  state  sometimes  lasted 
more  than  a  single  day.  You  may,  therefore,  apply  blisters  as  excit- 
ants and  stimulants ;  yet  there  are  many  persons  who  seem  to  forget 
this  distinction.  If,  in  a  case  of  inflammation  occurring  in  a  low  state 
of  the  system,  you  propose  to  apply  a  certain  number  of  leeches  over 
the  inflamed  organ,  they  say  no ;  but  they  have  no  hesitation  in  ap- 
plying a  large  blister,  leaving  it  on  until  it  produces  full  vesication, 
and  thus  abstracting  a  considerable  portion  of  white  blood  from  the 
system. 

Tou  will  not  expect  me  to  lay  down  any  general  rules  for  the  use 
and  application  of  blisters  in  fevers;  you  will  find  all  these  matters 
sufficiently  explained  in  your  books  and  manuals.  I  am  not  giving 
anything  like  a  regular  outline  of  the  treatment  of  fever ;  in  fact,  I 


BLISTERS    IN    FEVER.  151 

pass,  per  saltum,  from  one  point  to  another,  without  any  attention  to 
order  or  method.  You  can  read  methodical  treatises,  and  then  com- 
pare them  with  such  detached  observations  as  I  shall  make.  And  here 
aUow  me  to  make  some  cursory  remarks  on  that  peculiar  state  of  the 
brain  which  we  most  commonly  observe  in  the  middle  stage  of  typhus, 
and  in  which  blisters  form  one  of  our  most  efficient,  and  in  some  in- 
stances our  only  mode  of  relief.  In  many  of  the  cases  of  typhus  wliich 
come  under  our  observation  in  hospital,  we  frequently  meet  with  a  train 
of  S3T:nptoms  strongly  calculated  to  perplex  and  puzzle,  and  which 
should  seldom  exist  in  fever  regularly  treated ;  these  are  chiefly  cases 
which  are  admitted  in  the  middle  or  latter  stage  of  the  disease,  and  at 
a  period  when  the  patients  state  of  intellect  is  such  as  to  preclude  the 
hope  of  obtaining  any  satisfactory  information  from  a  personal  exami- 
nation. 

A  man  in  the  lowest  class  of  life,  and  at  a  distance  from  medical 
aid,  is  attacked  with  fever ;  for  the  first  eight  or  ten  days  he  is  either 
improperly  treated  or  altogether  neglected,  and  in  this  state  symptoms 
arise  and  superinduce  others,  causing  the  most  unfavourable  compli- 
cations, and  rendering  the  cure  difiicult,  if  not  impossible.  Now,  of 
aU  the  symptoms  which  occur  in  cases  of  fever,  where  the  state  of  the 
principal  organs  has  been  neglected,  there  are  none  more  formidable, 
or  more  fatal,  than  the  cerebral ;  nor  is  there  any  local  affection  in 
fever,  in  which  the  value  of  prevention  is  so  unequivocal  and  decided. 
What  I  wish  to  impress  upon  you  is,  that  you  should  always  anticipate 
the  cerebral  symptoms  in  fever.  Never  allow  the  cerebral  symptoms  to 
explode — watch  the  first  scintillse  of  cerebral  excitement — repress  the 
commencing  mischief,  and  do  not  permit  your  patient  to  be  overtaken 
by  formidable  inflammation  of  the  brain. 

Every  writer  will  tell  you  that  when  the  patient's  face  is  flushed,  his 
eyes  suffused,  and  when  he  complains  of  headache  and  intolerance  of 
Kght,  you  should  leech  and  bhster  his  head,  give  him  purgatives,  tartar 
emetic,  James's  powder,  and  the  medicines  calculated  to  bring  down 
cerebral  excitement :  but  a  careful  and  observant  practitioner  will  anti- 
cipate all  these  symptoms,  although  there  is  as  yet  no  particular  flushing 
of  the  face,  headache,  or  suffusion  of  the  eyes ;  and  though  the  pa- 
tient is  still  quite  rational,  he  will  recognise  threatening  disease  of  the 
brain,  and  take  proper  steps  to  prevent  its  increase.  Watch  the  func- 
tions of  the  brain  attentively,  and  they  will  inform  you,  in  almost  every 
case,  of  the  approach  of  cerebral  symptoms. 

You  will  find  in  patients  who  are  about  to  have  cerebral  symptoms, 
a  degree  of  restless  anxiety,  and  a  higher  degree  of  energy  than  accords 
with  their  condition ;  and  they  either  do  not  sleep  at  all,  or  their  sleep 


152  CLINICAL   MEDICINE. 

is  broken  by  startings  and  incoherent  expressions.  When  you  speak  to  a 
person  in  this  state,  he  answers  in  a  perfectly  rational  manner ;  he  will 
teU  you  that  he  has  Httle  or  no  headache ;  and  were  you  to  be  led  away 
by  a  hasty  review  of  his  symptoms,  you  would  be  very  likely  to  over- 
look  the  state  of  the  brain.  If  you  inquire  closely,  you  will  find  that 
he  scarcely  ever  sleeps,  or  even  dozes— that  he  is  irritable,  excitable, 
frequently  incoherent,  and  muttering  to  himself.  Under  such  circum- 
stances, although  there  is  no  remarkable  heat  of  scalp,  suffusion  of  the 
eye,  or  headache,  I  am  frequently  led  to  suspect  the  supervention  of 
cerebral  symptoms,  particularly  about  the  ninth  or  tenth  day  of  the 
fever  (for  it  is  generally  about  this  period  that  cerebral  symptoms  begin 
to  manifest  themselves) ;  and  whenever  I  observe  these  premonitory 
indications,  I  never  hesitate  in  taking  proper  measures  to  anticipate  the 
evil.  I  immediately  order  the  hair  to  be  shaved  off,  and  blister  the 
whole  scalp.  Thus,  at  the  period  when  disease  of  the  brain  would 
most  probably  have  set  in,  I  have  the  whole  external  surface  of  the 
head  pouring  out  serum,  or  even  suppurating ;  and  when  by  this  treat- 
ment I  have  opposed  a  barrier  to  the  further  progress  of  the  disease, 
the  exliibition  of  a  little  tartar  emetic  will  soon  remove  every  trace  of 
it.  In  laying  down  this  plan  of  treatment,  I  have  supposed  that  the 
patient  has  been  properly  treated  from  the  beginning,  and  that  the 
earher  symptoms  of  inflammatory  excitement  have  been  combated  by 
bleeding,  leeching,  and  other  appropriate  depletory  measures. 

There  is,  on  the  other  hand,  an  opposite  state  of  the  patient,  which 
in  like  manner  informs  me  that  danger  to  the  brain  is  at  hand.  In  tliis 
case,  the  patient  is  almost  continually  sleeping.  When  you  enter  his 
chamber  in  the  morning,  and  ask  how  he  does,  liis  attendant  generally 
teUs  you  that  he  has  passed  the  night  most  favourably,  and  that  he  has 
slept  without  almost  ever  waking  since  your  visit  on  the  preceding 
afternoon.  If  he  awakens  to  take  drink,  he  quickly  drops  asleep  again, 
and  when  you  arouse  him  he  looks  rather  heavy ;  there  is  some  slight 
suffusion  of  the  tunica  adnata,  and  some  appreciable  congestion  about 
the  external  parts  of  the  face  and  head.  Persons  in  this  state,  though 
apparently  doing  well,  and  even  where  they  have  been  properly 
treated  in  the  beginning,  about  the  ninth  or  tenth  day  begin  to 
rave,  and  exhibit  undoubted  proofs  of  congestion  and  excitement  of 
the  brain. 

Now,  in  all  cases  of  this  description  be  on  your  guard,  and  do  not 

allow  symptoms  of  dangerous  import  to  steal  on  you.     Here  you  will 

derive  great  benefit  from  the  use  of  bhsters.     I  was  lately  called  to  a 

very  remarkable  case  of  this  kind,  at  some  distance  from  Dublin.     The 

.  patient  slept  almost  constantly,  and  complained  of  no  headache  or  heat 


BLISTERS    IN    ELVER.  153 

of  scalp.  From  au  attentive  examination  of  the  case,  however,  I  was 
led  to  predict  the  approach  of  cerebral  symptoms.  Observe  this  was  a 
case  of  spotted  fever ;  and  in  this  form  of  fever  you  can  predict  the 
occurrence  of  such  symptoms  with  a  greater  degree  of  confidence.  The 
patient's  pulse  was  96,  his  tongue  presenting  nothing  worthy  of  remark, 
his  behaviour  and  speech  rational,  and  his  sleep  almost  constant.  Re- 
collecting, however,  the  period  of  the  fever,  and  observing  carefully  the 
condition  of  the  cerebral  functions,  I  had  his  head  shaved  and  blistered. 
Notwithstanding  this  precaution,  his  cerebral  symptoms  had  proceeded 
so  far  that  he  subsequently  got  a  slight  attack  of  paralysis  of  the  face 
and  tongue,  accompanied  by  a  fixed  state  of  the  pupils,  which  would 
neither  contract  nor  dilate.  After  having  blistered  his  head  extensively, 
I  gave  him  the  tartar  emetic  solution,  to  the  amount  of  one-eighth  of  a 
grain  every  second  hour.  The  measures  were  completely  successful 
in  removing  the  cerebral  symptoms,  and  I  have  no  doubt  that  the 
active  precautions  which  had  been  taken  were  the  means  of  saving  his 
life. 

There  is  one  symptom  connected  with  cerebral  excitement  in  fever 
which  is  well  worthy  of  your  notice,  as  its  existence  is  often  sufficient 
of  itself  to  give  timely  intimation  of  the  approach  of  irritation  or  in- 
flammation of  the  brain.  This  is,  the  state  of  the  respiratory  function. 
In  fever,  the  breathing  will  often  announce  the  approach  of  cerebral 
symptoms  for  days  before  their  actual  occurrence.  When,  in  cases  of 
typhus,  you  find  the  patient's  breathing  permanently  irregular,  and  in- 
terrupted by  frequent  sighing — when  it  goes  on  for  one  or  two  minutes 
at  one  rate,  and  then  for  a  quarter  or  half  a  minute  at  another  rate, 
you  may  rely  upon  it  that  sooner  or  later  an  affection  of  the  brain  will 
make  its  appearance.  You  will  frequently  observe  the  same  kind  of 
breathing  preceding  attacks  of  apoplexy  and  paralysis,  and  indeed  it 
was  the  occurrence  of  this  symptom,  in  these  and  other  cases  in  which 
the  functions  of  the  brain  were  deranged,  that  first  drew  my  attention 
to  this  kind  of  breathing.  The  first  time  it  engaged  my  attention  was 
in  a  remarkable  case  of  an  apoplectic  nature,  which  I  sat  up  a  whole 
night  to  watch.  On  recollection,  I  found  that  1  had  frequently  ob- 
served an  analogous  state  of  the  respiratory  function  in  fever,  on  several 
occasions,  although  its  connection  with  excitement  of  the  brain  had  not 
struck  me  before.  I  speak  here  of  irregularity  of  breathing,  indepen- 
dent of  any  pectoral  affection.  But  when  the  patient  breathes  in  a 
permanently  irregular  manner,  at  one  time  at  a  certain  rate,  and  at 
another  at  a  different  rate, — when  his  respiration  is  suspicious  and  heav- 
ing, without  any  disease  of  the  chest  or  great  debility, — ^you  will  have 
some  grounds   to  suspect  the  existence  of  cerebral  derangement.     I 


154  CLINICAL   MEDICINE. 

am  in  tlie  habit  of  calling  this  kind  of  breathing  cerebral  respiration, 
because  my  experience  has  told  me  that  it  is  almost  invariably  connected 
with  oppression  and  congestion  of  the  brain. 

To  recapitulate : — When  you  find  a  patient  in  fever  lying  constantly 
awake,  or  when,  on  the  contrary,  you  find  him  continually  slumbering, — 
when  there  is  a  certain  quickness  of  manner  and  irritabihty, — and  when 
the  cerebral  respiration  has  been  noticed  for  some  time,  without  any 
concurrent  debihty  or  pulmonary  disease, — under  such  circumstances, 
you  may,  in  cases  of  maculated  typhus,  predict  the  approach  of  cere- 
bral symptoms ;  and  the  period  about  which  they  generally  manifest 
themselves,  is  the  eight,  ninth,  or  tenth  day.  Now,  in  cases  of  this 
description, — if  you  have  previously  used  leeches  and  antiphlogistics  to 
a  sufficient  extent, — ^your  best  plan  will  be  to  shave  and  blister  the 
whole  scalp. 

Dr.  Little,  of  Belfast,  and  Mr.  Kirby,  of  this  city,  have  fallen  into 
the  same  train  of  ideas,  and  employ  blisters  at  a  very  early  period  of 
the  disease,  with  the  view  of  combating  cerebral  excitement.  In  a 
recent  instance,  in  private  practice,  I  think  I  saved  the  life  of  a  young 
gentleman  in  Harcourt-street  by  extensive  blistering  of  the  scalp  on  the 
fourth  day  of  fever.  "We  were  not  accustomed  to  blister  at  this  early 
period  of  fever.  Formerly  it  was  the  practice  to  bleed  and  apply 
leeches  for  several  days  together,  and  never  to  have  recourse  to  blister- 
ing until  towards  the  latter  stage  of  the  disease.  In  common  inflam- 
mation, or  in  arachnitis,  we  do  not  blister  until  we  have  carried  deple- 
tion by  the  lancet,  leeches,  and  purgatives,  as  far  as  the  patient^  s 
strength  will  allow.  But  this  is  not  the  case  in  fever :  the  cerebral 
congestion  and  irritation,  or  inflammation,  (call  it  which  you  will,) 
which  accompanies  typhus,  differs  essentially  from  ordinary  arachnitis 
or  encephalitis,  and  requires  very  often  a  treatment  strikingly  dif- 
ferent. 

One  physiological  fact  connected  with  sleep  may  be  noticed  here.  It 
has  been  stated  by  Mr.  Mayo,  that  the  pupils  are  contracted  during 
sleep.  This  is  in  itself  a  very  curious  fact,  and  I  was  anxious  to  verify 
it.  Now  we  had  an  excellent  opportunity  yesterday  morning  of  trying 
what  the  state  of  the  pupil  was  in  two  patients  who  lay  soundly  sleeping 
in  the  fever  ward.  We  came  up  softly  to  them  as  they  lay  on  their 
backs,  and  in  a  most  favourable  situation  for  observation,  just  opposite 
one  of  the  windows ;  and  having  opened  the  eye-lids,  found  that  the 
pupil  was  actually  contracted  to  the  size  of  a  pin-hole.  It  remained  in 
this  state  for  a  while,  and  then  expanded,  when  they  awakened.  This 
is  a  very  curious  fact,  and  appears  to  be  a  very  beautiful  instance  of  the 
protective  care  of  nature.     To  protect  the  eye  while  we  sleep,  nature,  as 


BLISTERS    IN    FEVEK.  15 


00 


it  were,  draws  the  curtain^  and  thus  defends  the  delicate  organ  from  any 
accidental  dazzHng,  at  a  period  when  consciousness  slumbers,  and  is  off 
its  guard. 

I  have  hitherto  spoken  of  blistering  in  fever  chiefly  as  a  powerful  re- 
vulsive remedy  in  the  treatment  of  cerebral  congestion ;  let  us  now  treat 
of  its  employment  with  other  objects  in  view.  In  the  first  place,  as  has 
been  already  explained^  blisters  may  be  used  as  most  energetic  stimulants 
in  cases  where  the  powers  of  life  flag,  and  threaten  a  sudden  cessation. 
Occasionally,  in  fever,  you  will  find  the  vital  tone  reduced  to  a  very 
low  pitch,  the  heart  uncertain  in  its  action,  the  pulse  irregular,  the  res- 
piration feeble,  the  skin  cool,  and  the  patient  so  weak  that  he  cannot  be 
lifted  up,  or  even  turned  in  bed,  without  having  a  tendency  to  faint. 
Here  we  have  to  superadd  to  the  ordinary  treatment  of  fever  the  prompt 
exhibition  of  remedies  calculated  to  meet  such  emergencies,  and  in  addi- 
tion to  internal  stimulants,  we  have  recourse  to  powerful  stimulation  of 
the  cutaneous  surface  by  what  are  termed  flying  blisters.  One  of  the 
best  remedies  in  such  cases  is  a  large  blister  applied  over  the  region  of 
the  heart,  to  be  left  on  for  two  or  three  hours,  or  until  the  vascular 
action  of  the  skin  is  sufliciently  excited.  Wlien  the  patient  appears  to 
labour  not  only  under  sudden  weakness  of  the  heart,  but  also  of  the  ca- 
pillary and  nervous  systems,  as  shown  by  coldness  of  the  extremities 
and  sinking  of  the  pulse,  it  will  be  necessary  to  apply  flying  blisters,  not 
oidy  over  the  region  of  the  heart,  but  also  over  various  parts  of  the 
chest,  the  epigastrium,  and  the  inside  of  the  legs  and  thighs.  You  will 
find  this  plan  of  treatment  frequently  succeed  in  cases  which  have  a 
very  unpromising  aspect.  I  have  now  witnessed  many  instances  of  this 
description,  in  which,  from  cold,  neglect,  or  debilitating  treatment,  the 
patients  appeared  moribund,  with  Kvidity  of  the  extremities,  hippocratic 
face,  cold  skin,  and  failing  pulse ;  and  I  have  seen  them  saved,  as  it 
were  miraculously,  by  the  use  of  carbonate  of  ammonia,  musk  and  wine, 
and  the  application  of  warm  fomentations  to  the  Hmbs,  followed  by  a 
succession  of  flying  blisters. 

Let  us  take  as  an  illustration  the  case  of  Christopher  Nolan,  which  I 
trust  you  have  all  watched  with  attention.  When  this  man  came  into 
the  hospital,  his  condition  appeared  to  be  completely  desperate,  he  has, 
however,  not  only  ralhed,  but  is  now  convalescing  rapidly.  It  is  unne- 
cessary for  me  to  enter  into  a  detail  of  liis  case,  as  I  trust  you  have  all 
observed  it  through  its  difi'erent  stages ;  I  shall  only  remark,  that  on 
his  admission  he  was  labouring  under  fever  of  the  worst  character,  his 
body  was  covered  with  maculse,  he  lay  constantly  on  his  back,  and  had 
low  mutterhig  delhium,  w^as  unable  or  unwilHng  to  answer  questions, 
his  breathing  was  oppressed,  his  pulse  rapid,  small  and  failing,  the 


156  CLINICAL    MEDICINE. 

powers  of  life  awfully  prostrated, — in  fact,  lie  was  in  a  state  of  appa- 
rently threatening  dissolution. 

My  first  object  was  to  rouse  the  sinking  powers  of  the  system,  and 
with  that  view  I  adopted  the  following  treatment.  He  was  put  into  a 
comfortable  bed,  and  heat  was  restored  to  the  surface  by  diligently  rub- 
bing his  trunk  and  limbs  with  warm  flannel.  I  next  ordered  a  suc- 
cession of  flying  bhsters  to  the  neck,  chest,  and  abdomen.  I  may 
observe  here,  that  his  chest  was  heaving,  there  was  a  general  wheezing 
audible  over  the  whole  surface,  and  he  had  that  peculiar  livid  expression 
of  countenance  and  dusky  hue  of  skin,  which  indicate  an  imperfect 
aeration  of  the  blood.  With  the  view  of  stimulating  the  oppressed 
action  of  the  respiratory  nerves,  I  had  two  blisters  applied,  one  on  each 
side  of  the  neck,  above  the  clavicle ;  after  remaining  on  for  two  hours 
these  were  removed,  and  two  more  applied  over  the  supra-mammary 
region,  then  over  the  heart  and  right  side  of  the  chest,  and  lastly,  over 
the  epigastrium.  In  addition  to  this  he  was  ordered  to  have  wine  and 
chicken  broth,  and  a  stimulant  draught  was  prescribed,  to  be  taken  re- 
gularly every  second  hour  until  symptoms  of  reaction  began  to  appear. 

In  employing  blisters  in  this  case  my  object  was  to  stimulate  power- 
fully and  in  rapid  succession  the  integuments  of  the  neck,  chest,  and 
abdomen.  This  practice  has  in  such  cases  been  attended  with  very 
marked  results,  and  in  ours  proved  extremely  valuable.  Its  efficacy 
seems  to  depend,  not  on  the  discharge  of  serous  fluid,  or  on  any  revul- 
sive action  of  the  blisters,  but  on  the  powerful  stimulus  applied  to  an 
extensive  cutaneous  surface. 

Blisters  applied  extensively  to  the  shaven  scalp,  are  not  only  valuable 
in  fever,  but  also  in  other  diseases,  and  that  under  circumstances  in 
which  little  benefit  could  be  expected.  The  same  efi'ects  may  be  pro- 
duced by  rubbing  the  whole  scalp  with  tartar  emetic  ointment ;  but 
from  the  pain  and  inflammation  it  produces,  this  proceeding  is  seldom 
adopted.  I  have,  however,  occasionally  employed  it ;  and  on  two  re- 
cent occasions  with  the  most  fortunate  results.  A  friend  of  mine  had 
lost  two  children  from  hydrocephalus.  About  five  weeks  ago  another 
child,  an  extremely  fine  boy,  was  attacked  with  symptoms  of  the  same 
disease.  After  having  laboured  for  a  fortnight  under  fever,  with  great 
restlessness,  vomiting,  and  diarrhoea,  he  was  observed  to  utter  frequently 
that  faint  cry  which  is  so  characteristic  of  hydrocephalus,  and  to  roll 
his  head  constantly  from  side  to  side.  These  symptoms  were  soon 
afterwards  succeeded  by  constant  motions  of  the  right  arm  and  leg, 
and  subsequently  by  paralysis  of  the  opposite  side.  I  was  consulted 
before  the  paralysis  occurred,  and  advised  the  child's  father  to  have  the 
whole  of  the  blistered  scalp  well  rubbed  with  tartar  emetic  ointment. 


BLISTERS  IN  FEVER.  157 

The  boy  recovered  completely.  I  derived  also  a  very  striking  advan- 
tage from  the  use  of  the  same  remedy  in  a  very  remarkable  epidemic 
which  attacked  a  family  in  the  neighbourhood  of  Rathmines,  and 
which  was  witnessed  throughout  its  whole  course  by  Dr.  Burke  and 
myself.  One  of  the  family,  a  young  lady,  was  attacked  with  symptoms 
of  fever,  accompanied  by  a  pain  in  the  back  of  the  head,  and  stiffness 
of  the  neck.  After  a  few  days,  symptoms  of  inflammation  of  the  cere- 
bellum and  upper  part  of  the  spinal  cord  became  developed.  About 
the  seventh  day  she  got  strabismus,  and  soon  afterwards  was  attacked 
with  convulsions  :  the  pupil  became  permanently  dilated,  and  she  was 
quite  blind.  I  was  called  to  see  her  at  this  period,  and  found  her  al- 
most in  a  state  of  insensibility,  with  involuntary  discharge  of  urine  and 
feces,  cold  extremities,  and  irregular  pulse.  Thinking  that  nothing 
could  be  done  for  her,  I  was  about  to  leave  the  room  when  I  asked  the 
nurse,  could  she  swallow?  She  replied  she  could,  and  immediately  pro- 
ceeded to  offer  the  young  lady  some  drink,  which  she  swallowed  with- 
out any  difficulty.  This  at  once  arrested  my  attention.  I  said  to  my- 
self, if  this  patient  can  swallow,  she  must  be  still  conscious,  and  while 
she  is  so,  there  is  a  chance  of  saving  her.  I  ordered  the  whole  of  the 
scalp,  which  had  been  previously  blistered,  to  be  rubbed  with  tartar 
emetic  ointment ;  violent  inflammation  ensued,  and  she  recovered  com- 
pletely. But  the  curious  part  of  the  case  is  this  : — her  brother  and 
sister  were  attacked,  in  exactly  the  same  way,  a  few  days  afterwards, 
although  less  formidably,  and  were  cured  by  the  same  treatment. 
Shortly  afterwards  two  of  the  servants  got  pain  in  the  back  of  the  head 
and  stiffness  of  neck,  followed  by  signs  of  an  inflammatory  affection  of 
the  cerebellum  and  spinal  cord.  They  were  treated  in  the  same  way, 
and  recovered. 

What  could  be  the  cause  of  this  peculiar  fever,  manifesting  itself  in 
exactly  the  same  way  in  all  the  individuals  of  the  family  who  were  at- 
tacked ?  I  endeavoured  to  arrive  at  the  cause,  but  could  not ;  and  I 
merely  state  the  facts,  without  wishing  to  attempt  any  thing  like  an 
explanation.  But  the  history  of  this  extraordinary  form  of  disease  is 
exactly  as  I  have  told  you. 

The  next  use  to  which  w^e  apply  blisters  is  in  the  treatment  of  those 
pulmonary  affections  which  arise  during  the  course  of  typhus.  From 
what  you  have  seen  of  the  present  epidemic,  you  must  be  convinced 
that  bronchitis  is  one  of  its  most  frequent  complications,  and  that  few 
persons  pass  through  fever  without  having  some  affection  of  the  bron- 
chial mucous  membrane.  You  are  also  aware,  that  when  bronchitis 
attacks  the  more  minute  ramifications  of  the  bronchial  tubes,  it  is  very 
apt  to  produce  congestion  and  engorgement  of  the  lung.  -  We  meet 


158  CLINICAL    MEDICINE. 

with  pneumonia  much  less  frequently  in  fever,  but  it  is  occasionally 
observed,  and  requires  the  most  prompt  and  decided  treatment.  In 
pneumonia,  as  well  as  in  congestion  of  the  lungs  accompanied  by  in- 
flammation of  the  smaller  bronchial  tubes,  blisters  afPord  us  a  most  va- 
luable adjunct  to  the  other  means  which  we  employ,  and  admit  of  being 
used  in  cases  where  no  other  mode  of  depletion  could  be  safely  borne. 

The  affections  of  the  lung  in  fever  are  of  no  small  importance,  and 
the  stethoscope  has  not  conferred  a  greater  benefit  on  practical  medi- 
cine, than  by  indicating,  in  diseases  of  the  chest,  not  merely  the  exis- 
tence of  disease,  but  also  its  locality,  extent,  and  precise  nature.  It 
points  out  to  us  the  portion  of  the  chest  in  which  the  bronchial  tubes 
are  chiefly  engaged,  and  informs  us  with  certainty  when  the  affection  of 
the  smaller  tubes  has  given  rise  to  pulmonary  engorgement.  The  ex- 
perienced stethoscopist  will  in  such  cases  be  aware  of  the  exact  site  and 
nature  of  the  affection,  where  the  mere  symptomatic  practitioner  would 
be  unable  to  acquire  any  tiling  more  than  a  loose  and  undefined  notion 
of  pulmonary  disease.  The  latter  employs  his  depleting  means  at  ran- 
dom, and  frequently  abstracts  a  large  quantity  of  blood  with  little  be- 
nefit to  his  patient ;  the  former,  aware  of  the  precise  situation  and  ex- 
tent of  the  disease,  applies  his  leeches  or  cupping  glasses  immediately 
over  the  engorged  or  inflamed  portion  of  the  lung,  and  relieves  liis  pa- 
tient at  the  expense  of  a  comparatively  small  loss  of  blood.  The  same 
observation  will  apply,  with  equal  force,  to  the  use  and  application 
of  blisters. 

A  good  and  accurate  knowledge  of  the  various  stethoscopic  pheno- 
mena is  besides  of  so  much  more  value  in  the  treatment  of  fever,  as  at 
certain  seasons  of  the  year,  almost  every  case  of  fever,  will  be  compli- 
cated with  pulmonary  derangement ;  and  it  may  happen,  during  the 
course  of  an  epidemic,  that  the  lungs  may  be  the  organs  which  are 
chiefly  engaged.  Although  cerebral  disease  is  at  present  the  principal 
source  of  danger  in  fever,  it  may  not  be  so  always.  A  change  may 
take  place  in  the  character  of  the  epidemic ;  the  cerebral  symptoms 
which  are  now  of  such  frequent  occurrence  may  become  unfrequent, 
and  we  may  have  the  organic  affections  chiefly  limited  to  the  viscera  of 
the  thorax.  I  have  seen  many  cases  of  fever  in  which  the  principal 
source  of  danger  was  connected  with  the  chest,  and  where  an  accurate 
knowledge  of  the  stethoscope  was  indispensable  to  a  correct  and  suc- 
cessful plan  of  treatment. 

Now,  when  you  have  recourse  to  blisters  in  treating  pulmonary 
affections,  whether  these  affections  be  simple  or  complicated  with 
typhus,  it  would  be  well  to  recollect  that  much  good  may  be  effected 
without  leaving  the  blisters  on  for  a  long  time,  or  until  they  rise  fully ; 


BLISTERS    IN    FEVER.  159 

and  also  that  when  risen,  it  will  not  be  necessary  to  cut  them  at  once 
and  let  out  the  effused  serum.  In  treating  the  bronchitis  of  children 
and  in  the  bronchial  affections  of  fever,  I  have  frequently  directed  the 
blister  to  be  left  unopened ;  and  I  can  state,  from  experience,  that  this 
plan  answers  very  well.  The  effused  serum  forms  one  of  the  best 
dressings  for  the  excoriated  surface  of  the  skin,  and  the  formation  of 
troublesome  sores  is  avoided.  I  frequently  have  recourse  to  this  mode 
of  treating  bhstered  surfaces  in  children,  and  persons  of  irritable  habit, 
in  whom  the  cutis  is  extremely  tender  and  vascular.  Such  persons, 
when  blistered,  will  often  have  profuse  discharges,  first  of  serum,  and 
afterwards  of  sero-purulent  matter,  from  the  denuded  surface,  accom- 
panied by  torturing  pain,  loss  of  rest,  and  considerable  irritation  of  the 
general  system.  I  have  seen  the  discharge  continue  to  flow  profusely 
for  five  or  six  days ;  in  fact,  to  such  an  extent  as  to  wet  several  napkins 
in  the  course  of  a  day,  and  expose  the  patient  to  the  risk  of  an 
aggravation  of  the  pulmonary  symptoms,  in  consequence  of  his  linen 
becoming  so  frequently  moistened  as  to  require  repeated  shifting.^ 

In  all  cases  of  children  and  persons  of  an  irritable  habit,  I  would 
therefore  advise  you  to  let  the  blisters  alone,  particularly  where  they 
have  been  applied  to  the  fore  part  of  the  chest,  or  any  other  part  not 
exposed  to  pressure  or  friction.  As  soon  as  the  blister  rises,  apply 
over  it  a  piece  of  hnt,  smeared  with  spermaceti  ointment,  which  can 
be  renewed  as  occasion  requires,  and  leave  the  rest  to  nature.  I  was 
forcibly  struck  some  time  since,  with  the  difference  of  result  between 
this  and  the  ordinary  practice,  in  the  case  of  a  young  gentleman  resid- 
ing in  Camden  Street  who  had  a  severe  attack  of  bronchitis  towards 
the  termination  of  fever.  A  blister  had  been  applied  to  his  chest  in 
the  morning,  and  another  in  the  middle  of  the  day.  The  first  had  been 
opened  freely,  and  dressed  in  the  usual  way ;  but  the  other,  wliich  had 
risen  about  the  time  I  was  called  in,  was  left  untouched  at  my  request. 
The  one  which  had  been  opened  caused  such  a  degree  of  irritation 
and  restlessness,  that  it  was  found  necessary  to  give  him  an  opiate  every 
night ;  the  other  gave  little  or  no  inconvenience,  and  healed  up  much 
sooner.  A  still  better  method  is  that  recently  proposed  by  Dr. 
Douglas  Maclagan,  of  Edinburgh — dressing  the  blistered  surface  with 
cotton:  the  blister  is  left  on  for  five  or  six  hours,  according  to  cir- 
cumstances, a  poultice  then  applied  for  two  hours,  and  the  raised 
cuticle  having  been  removed  with  a  pair  of  scissors,  the  raw  surface  is 

*  In  pulmonary  diseases,  this  continued  discharge  is  often  very  useful,  and  should  be 
encouraged,  by  dressing  the  vesicated  surface  with  the  French  blistering  paper,  or,  what  I 
have  found  equally  useful,  that  prepared  by  Mr.  Bewley,  of  this  city:  but  in  fever  the 
production  of  such  effects  from  blisters  inust  be  avoided,  as  a  surface  thus  denuded  of  it? 
cuticle,  and  inflamed,  may  be  converted  into  a  dangerous  sore. 


160  CLINICAL    MEDICINE. 

covered  with  a  thick  layer  of  French  wadding ;  it  heals  completely  in 
about  twenty-four  hours,  but  is  so  little  painful  after  twelve  hours,  that 
percussion  and  auscultation  may  be  performed  over  the  part — of  course 
without  disturbing  the  cotton,  a  matter  of  much  importance  in  pulmo- 
nary affections. 

If  I  have  done  nothing  better,  I  think  I  deserve  some  merit  for  being 
the  first  to  reprobate  the  practice  of  keeping  on  blisters  for  twelve, 
eighteen,  and  twenty-four  hours,  and  for  having  shown,  by  numerous 
experiments,  that  a  much  shorter  period  of  time  was  required  to  ensure 
the  full  effect  of  these  remedies.  When  I  commenced  the  practice  of 
medicine,  blistering  was  looked  upon  by  most  sick  persons  as  one  of 
the  severest  trials  of  their  patience,  and  the  agony  which  it  caused  in 
some  irritable  habits  was  almost  insupportable.  Blisters  were  left  on 
for  twelve,  eighteen,  and  even  twenty-four  hours,  and  when  at  length 
they  were  removed,  the  whole  epidermis  of  the  blistered  part  came,  or 
was  torn  away,  leaving  behind  a  raw  irritable  surface,  from  which  large 
quantities  of  serum  and  pus  were  effused  for  several  days,  to  the  great 
torture  and  inconvenience  of  the  patient;  and,  not  content  with  this, 
the  practitioners  of  that  time  generally  dressed  the  excoriated  surface 
with  some  sharp  stimulant  ointment,  so  that  the  blistered  surface  most 
commonly  resembled  that  of  a  severe  burn. 

Ask  those  who  are  our  seniors  in  practice,  and  they  will  tell  you  what 
blistering  was  some  thirty  or  forty  years  ago.  They  first  produced  ex- 
cessive irritation  of  the  skin,  by  leaving  the  blisters  on  too  long,  they 
then  irritated  the  denuded  surface  with  stimulating  ointments,  and  in 
this  way  brought  on  extensive  sores  of  a  bad  character,  which  remained 
long  after  the  disease  for  which  the  blisters  were  applied  had  disappeared, 
and  which  formed,  in  fact,  a  new  ailment,  requiring  new  medicines  and 
additional  attendance.  If  you  look  over  Mr.  Moore's  account  of  the 
principal  remedies  employed  in  the  practice  of  Dubhn  physicians,  about 
the  period  I  allude  to,  published  in  the  10th  volume  of  the  Dublin 
Journal  of  Medical  Science,  you  will  find  that  nothing  was  more  com- 
mon then  than  the  application  of  stimulant  and,  as  they  were  termed, 
digestive  ointments,  to  blistered  surfaces.  I  was  among  the  first  who 
assailed  this  barbarous  treatment,  and  showed  that  all  the  good  effects 
of  blisters  might  be  secured  by  leaving  them  on  for  a  much  shorter  space 
of  time.  I  proved  by  numerous  experiments,  that  in  many  cases  it  was 
not  necessary  to  leave  them  on  more  than  four  or  five  hours,  in  the 
adult,"^  and  that  they  might  then  be  removed  and  the  blistered  part 

*  Of  course  blisters  applied  to  the  scalp  must  be  excepted.  They  require  at  least 
twelve  hours.  In  old  persons  generally  the  skin  is  much  less  vascular  than  during  youth 
and  middle  age  ;  and  consequently,  in  the  old,  blisters  require  a  much  longer  time  to 
produce  the  desired  efFect. 


BLISTERS  IN  FEVER.  16 i 

dressed  with  spermaceti  ointment.  In  addition  to  tliis,  you  entirely 
avoid  the  irritating  effects  which  bhsters  are  known  to  produce  on  the 
urinary  organs.  You  will  very  rarely  meet  with  dysuria,  or  hematuria, 
where  the  blister  has  been  left  on  for  the  spaces  of  time  I  have  men- 
tioned. 

Blistering  is  then  to  be  used  with  the  restrictions  I  have  mentioned, 
and  you  will  find  it  a  most  valuable  aid  in  the  treatment  of  fever  and  its 
complications.  It  may  be  employed  either  as  a  derivative  and  revulsive^ 
or  you  may  have  recourse  to  flying  blisters  over  various  parts  of  the 
body,  in  certain  forms  of  fever,  where  there  is  marked  and  sudden  de- 
pression of  the  powers  of  life. 

Speaking  of  depression  of  the  powers  of  life,  reminds  me  of  a  cu- 
rious incident  which  occurred  some  time  ago  in  my  practice,  and  which 
shows  the  value  of  being  acquainted  with  the  peculiar  habits  and  idiosyn- 
crasies of  families.  I  attended,  with  Mr.  Kirby,  about  three  years 
since,  a  gentleman  of  middle  age  and  active  professional  habits,  who 
had  been  attacked  with  fever.  I  w^as  first  called  to  see  him  on  the 
ninth  day  of  fever,  and  found  him  apparently  moribund.  His  pulse 
was  intermittent  and  irregular,  the  action  of  the  heart  tumultuous,  the 
respiration  feeble,  and  the  extremities  cool.  Mr.  Kirby  had  instantly 
ordered  internal  stimulants,  and  blisters  to  the  region  of  the  heart  and 
epigastrium.  The  patient  rallied,  and  ultimately  recovered.  It  is  to 
be  observed,  that  the  group  of  formidable  symptoms  just  enumerated 
had  supervened  quite  out  of  the  usual  course,  and  without  any  previous 
warning.  They  were  consequently  not  only  alarming  but  unexpected. 
About  a  month  afterwards,  Mr.  Smyly  and  I  were  called  to  see  this 
gentleraan^s  brother,  who  was  living  at  Dundrum,  and  who  was  sup- 
posed to  have  caught  fever  from  his  close  attention  on  his  brother  during 
his  illness  and  convalescence.  What  w^as  most  remarkable  in  the 
case,  was,  that  his  pulse  began  to  flag  and  intermit,  and  he  likewise 
suddenly  and  unexpectedly  got  the  same  symptoms  of  depression  of  the 
vital  powers  on  the  very  same  day  and  hour  as  his  brother.  His  symp- 
toms also  continued  for  the  same  length  of  time,  and  yielded,  or  spon- 
taneously ceased,  under  the  same  plan  of  treatment.  In  some  families 
you  will  find  a  very  curious  coincidence  between  the  play  of  the  various 
functions  in  disease  as  well  as  in  health,  and  you  should  neglect  no  op- 
portunity of  making  yourself  acquainted  with  the  family  peculiarities 
and  idiosyncrasies  of  your  patients,  as  knowledge  of  this  description 
is  of  the  greatest  value  and  importance  in  the  treatment  of  disease. 


VOL.  I.  11 


162 


LECTURE  XIIT. 

WAUM  FOMENTATIONS  TO  THE  HEAD  IN  FEVER. USE  OF  MERCURY. — ■ 

SUBSULTUS  TENDINUM. CEREBRAL  SYMPTOMS. 

I  have  already  laid  before  you  my  views  as  to  the  use  of  general  and 
local  bleeding  in  fever,  and  pointed  out  the  circumstances  under  which 
they  might  be  employed.  In  treating  of  general  bleeding,  I  stated 
that  we  used  it  at  the  commencement  of  fever,  with  a  view  of  checking 
the  disease  altogether,  or  of  rendering  it  milder  and  less  dangerous,  by 
moderating  excessive  inflammatory  action,  and  controUing  cerebral 
excitement.  I  have  also  spoken  of  the  use  of  leeches  and  blisters,  and 
it  only  remains  for  me  to  say  a  few  words  respecting  the  application  of 
cold  to  the  head  as  a  means  of  moderating  or  removing  symptoms  of 
cerebral  excitement. 

In  Dr.  Southwood  Smithy's  Treatise  on  Eever,  you  will  find  many 
cases  and  arguments  to  shew  that  where  headache  and  delirium  are 
present,  and  where  the  lancet  is  inadmissible,  if  you  place  the  patient 
in  a  warm  bath,  and  direct  a  forcible  small  stream  of  very  cold  water 
on  his  head,  he  soon  becomes  more  calm,  experiences  great  relief  of 
his  headache,  and  is  frequently  brought  back  to  bed  quite  free  from 
cerebral  symptoms.  The  burning  heat  of  the  skin  is  quickly  replaced 
by  a  sensation  of  coolness,  or  even  cold,  the  flushing  of  the  face  dis- 
appears, the  delirium  vanishes,  and  a  favourable  crisis  is  often  pro- 
duced. Indeed  the  effects  of  this  remedy  are  extremely  remarkable, 
and  I  have  no  doubt  that  many  of  the  cases  in  which  I  have  employed 
tartar  emetic  with  such  signal  advantage  would  derive  equal  benefit 
from  this  mode  of  treatment. 

The  cold  affusion,  as  recommended  by  Dr.  Smith,  and  practised  at 
the  Charite  Krankenhaus,  at  Berlin,  is  most  certainly  an  excellent  and 
energetic  remedy,  and  I  regret  that  we  have  not  apparatus  in  this 
hospital  for  applying  it ;  but  I  fear  its  utility  must  be,  at  least  for  some 
time,  hmited  to  public  institutions,  and  that  it  cannot  be  employed  to 
any  extent  in  private  practice.     There  is  a  good  deal  of  prejudice 


WARM  FOMENTATIONS  TO  THE  HEAD  IN  FEVEIl.  163 

against  applications  of  the  kind  in  this  country.  At  the  time  that  cold 
affusions  were  used  in  the  treatment  of  scarlatina,  much  mischief  was 
done  by  their  indiscriminate  employment,  and  this  added  to  the  general 
feeling  of  dislike  towards  them.  At  all  events,  cold  affusion  is  a  re- 
medy which  requires  an  apparatus  seldom  at  the  command  of  the  phy- 
sician in  private  families,  and,  indeed,  I  think  that  in  most  cases  we 
may  do  very  well  without  it. 

You  are  all  aware,  that  in  cases  of  determination  to  the  head,  the 
common  practice  is  to  shave  the  scalp,  and  apply  cold  lotions.  In  my 
lectures  I  have  repeatedly  pointed  out  the  imperfect,  and  even  hurtful, 
mode  in  which  this  remedy  is  ordinarily  applied,  and  endeavoured  to 
show  that  it  is  calculated  rather  to  increase  than  diminish  the  heat  of 
the  integuments.  Cold  lotions  act  as  a  powerful  refrigerant,  if  con- 
stantly repeated,  so  as  to  keep  the  part  below  the  standard  temperature 
of  the  body.  But  this  is  seldom  or  never  done.  The  nurse  applies 
the  lotion,  and  then,  perhaps,  drops  asleep,  or  occupies  herself  with 
some  other  business,  until  at  last  she  is  attracted  by  the  vapour  arising 
from  the  patient''s  head,  and  then  she  renews  the  application.  I  need 
not  say,  that  in  this  way  all  the  good  effects  of  cold,  as  a  refrigerant, 
are  entirely  lost,  and  that  a  degree  of  reaction  is  produced  which  must 
altogether  mar  and  nullify  its  application.  I  have,  therefore,  given  up, 
except  in  very  few  cases,  the  practice  of  applying  cold  lotions,  and  give 
a  preference  to  the  use  of  warm  fomentations  of  equal  parts  of  vinegar 
and  hot  water,  applied  to  the  temples  and  shaven  scalp,  and  frequently 
repeated.  I  am  quite  sure  we  employ  warm  applications  for  the  relief 
of  headache  and  cerebral  symptoms  much  less  frequently  than  we 
ought.  You  are  aware  that  surgeons  are  in  the  habit  of  treating  some 
local  inflammations  with  warm,  and  others  with  cold  applications,  and 
that  the  rules  laid  down  for  distinguishing  the  cases  in  which  cold,  and 
those  in  which  warm  fomentations  should  be  used,  are  deficient  in  pre- 
cision, and  that  most  commonly  the  practitioner  has  to  refer  to  his  own 
individual  experience  for  the  guidance  and  determination  of  his  choice. 
So  it  is,  also,  with  respect  to  the  use  of  fomentations,  to  relieve  the 
pain  and  congestion  of  internal  parts,  among  which  I  include  determi- 
nation to  the  head  in  fever,  accompanied  by  intense  headache,  restless- 
ness, and  delirium.  In  some  cases  of  this  description,  cold  applications 
will  give  ease ;  in  others,  most  rehef  is  obtained  by  fomenting  the  head 
with  water  as  hot  as  it  can  be  borne. 

The  idea  of  employing  hot  fomentations  in  cases  of  this  description 
was  first  communicated  to  me  in  1833,  by  the  late  Mr.  Swift,  who  be- 
came accidentally  aware  of  their  value  whilst  washing  his  face  one  day 
in  very  warm  water,  at  a  moment  Mhen  labouring  under  severe  head- 


164  CLINICAL    MEDICINE. 

ache.  The  sudden  relief  obtained  by  the  application  of  hot  water, 
induced  him  to  try  it  exclusively  in  the  headache  of  influenza,  and  with 
the  most  satisfactory  results.  In  the  influenza  which  appeared  in  this 
country  in  1833  and  1837,  and  again  recurred  in  1847,  one  of  the 
most  remarkable  symptoms  was  intense  headache.  This  was  accompanied 
by  great  debihty,  and  was  not  amenable  to  the  ordinary  modes  of 
depletion.  Now,  in  the  first  of  these  epidemics,  Mr.  Swift  found  that 
by  applying  water,  as  hot  as  it  could  be  borne,  to  the  forehead,  tem- 
ples, and  back  of  the  head,  great  and  almost  instantaneous  relief  was 
obtained,  and  that  in  this  way  he  was  able  to  keep  a  most  unpleasant 
symptom  in  check,  while  he  was  taking  measures  to  remove  the  disease. 
I  have  also  heard  from  my  friend.  Dr.  Oppenheim,  of  Hamburg,  that 
he  had  discovered  that  tliis  was  the  best  means  of  affording  relief  under 
the  same  circumstances.  Mr.  Swift's  observations  first  led  me  to  think 
of  applying  hot  fomentations  to  the  head  in  other  diseases,  and  although 
I  cannot  give  you  any  particular  rules  for  determining  the  cases  in 
which  you  should  employ  them,  I  can  say  that  you  will  generally  find 
warm  vinegar  and  water  the  best  and  most  efficacious  application  in  the 
ordinary  headache  of  fever. 

I  shall  next  offer  you  a  few  observations  on  the  use  of  mercury  in 
fever ;  and,  first,  are  we  to  have  recourse  to  mercury,  or  not,  in  typhus  ? 
I  do  not  allude  here  to  its  use  as  an  aperient ;  but,  when  called  to  treat 
a  case  of  fever,  are  you  to  proceed  at  once  to  bring  the  patient's  system 
under  the  influence  of  mercury  ?     Are  you,  in  addition  to  the  other 
measures  usually  adopted  in  the  treatment  of  fever,  to  go  on  with  the 
administration  of  mercury  until  you  affect  the  mouth,  and  bring  on 
salivation  ?     This  was  the  practice  in  my  earlier  days,  and  great  confi- 
dence was  placed  in  it  by  the  majority  of  practitioners.     It  has  been 
also  very  extensively  recommended  by  army  and  navy  surgeons,  in  the 
treatment  of  tropical  fevers,  but  I  must  confess  that  I  am  not  at  all 
inclined  to  adopt  this  practice,  and  that  I  have  seen  abundant  reasons 
why  I  should  neither  employ  nor  recommend  it.     In  the  first  place,  we 
have  observed  in  our  wards  that  patients  with  other  diseases  have  fre- 
quently caught  fever  from  exposure  to  infection,  at  a  time  when  they 
were  fully  under  the  influence  of  mercury.     In  the  next  place,  we  have 
observed  that  persons  who  were  thus  attacked  with  fever  while  in  a 
state  of  salivation  did  not  escape  better  than  others,  and  that  in  them 
the  disease  ran  its  full  course,  aggravated  rather  than  diminished  in  its 
danger  by  the  pre-existing  mercuriahsation.     These  facts  I  have  fre- 
quently seen  verified  in  hospital  and  private  practice. 

You  perceive,  then,  that  mercuriahsation  neither  protects  a  man  from 
the  contagion  of  typhus,  nor  does  it  produce  a  favourable  modification 


USE  OF  MERCURY  IN  FEVER.  165 

in  its  type  or  progress.  Again,  I  have  repeatedly  witnessed  the 
daily  and  continued  exhibition  of  mercury  in  fever,  and  I  cannot  recol- 
lect a  single  case  in  which  it  appeared  to  check  the  disease,  moderate 
its  symptoms,  or  bring  about  a  favourable  crisis.  I  am  aware,  that  in 
entering  my  protest  against  this  practice,  I  dissent  from  a  very  consid- 
erable body  of  my  brethren,  who,  from  the  beginning  to  the  end  of 
fever,  never  cease  in  their  attempts  to  bring  the  patient^s  system  under 
the  influence  of  mercury.  I  am  convinced  that,  in  the  cases  in  which 
recovery  is  stated  to  have  followed  this  practice,  the  post  hoc  has  been 
mistaken  for  the  propter  hoc.  Besides,  fever  is  one  of  those  affec- 
tions in  w^hich  you  will  find  it  extremely  difficult,  and  often  impossible, 
to  bring  the  system  fully  under  the  influence  of  mercury.  There  are 
certain  states  of  the  system  which  prevent  altogether  the  full  operation 
of  mercury,  and  bad  typhus  is  one  of  these  states.  Where  fever  has 
laid  deep  hold  of  the  constitution,  you  cannot  affect  it  with  mercury. 
When  a  patient  recovers  who  has  been  mercurialised  during  the  course 
of  fever,  he  does  not  recover  because  his  system  came  under  the  influ- 
ence of  mercury,  but  he  comes  under  the  influence  of  mercury  because 
he  recovers  from  the  fever.  Add  to  this,  that  mercury  is  a  remedy 
which  requires  a  peculiar  regimen,  and  that  it  is  very  apt  to  engross  the 
practitioner's  attention,  and  prevent  him  from  the  exhibition  of  reme- 
dies which  are  more  directly  indicated,  and  in  reality  more  useful. 

These  considerations,  and  others,  have  convinced  me  that  the  exhi- 
bition of  mercury  in  fever,  with  the  view  of  touching  the  gums,  is  inju- 
dicious and  unnecessary.  There  are,  however,  cases  in  which  you  wiU 
be  compelled  to  have  recourse  to  mercury,  whatever  the  stage  or  the 
ij^t  of  the  fever  may  be.  Whenever  inflammation  of  some  internal 
organ — as,  for  instance,  of  the  lungs — arises  during  the  progress  of 
fever,  you  must  employ  mercury  at  once ;  and  cases  of  pneumonia, 
which  would  have  proved  fatal,  have,  on  numberless  occasions,  been 
treated  successfully  by  mercurialisation.  But  under  ordinary  circum- 
stances, and  were  there  no  indication  similar  to  that  which  I  have  just 
pointed  out,  I  do  not  see  any  advantage  to  be  derived  from  the  use  of 
mercury.  I  am  not,  therefore,  in  the  habit  of  employing  mercury  in 
fever.  Sometimes  I  use  calomel  as  an  aperient,  and  I  frequently  pre- 
scribe small  doses  of  hydrargyrum  cum  creta,  with  the  view  of  gently 
stimulating  the  liver,  and  preventing  the  tendency  to  congestion  of  the 
intestinal  canal ;  but  farther  than  this  I  am  not  in  the  habit  of  going ; 
and  I  never,  except  in  cases  of  pneumonia,  or  inflammation  of  soijie 
internal  organ,  attempt  to  bring  the  patient's  system  under  the  influence 
of  mercury  during  the  course  of  typhus. 

Allow  me  here  to  digress  a  moment  from  my  subject,   and  make  a 


166  CLINICAL    MEDICINE. 

few  observations  on  the  case  of  the  man  Cassels^  which  terminated 
fatally  in  our  wards  within  the  last  twenty-four  hours.  I  wish  to  call 
your  attention  to  this  case  more  particularly,  as  I  think  a  different  plan 
of  treatment  might  have  succeeded  in  saving  the  man's  life.  This  man 
was  admitted  into  the  fever  ward  about  the  seventh  or  eighth  day  of 
his  illness.  I  cannot  exactly  state  how  he  was  treated  in  the  commence- 
ment, but  I  beheve  he  was  very  badly  attended,  and  tliat  the  state  of 
the  principal  organs  was  wholly  neglected.  It  will  be  sufficient  to  ob- 
serve, that  when  he  came  under  our  care  the  chief  features  of  his  case 
were  delirium,  accompanied  by  total  want  of  sleep,  and  a  violence  of 
conduct  and  behaviour  calling  for  the  restraint  of  the  strait  waistcoat. 
Now  under  circumstances  of  this  nature  the  most  diligent  attention 
and  promptitude  are  imperatively  demanded  on  the  part  of  the  physi- 
cian, and  every  step  calculated  to  anticipate  danger  should  be  instantly 
taken.  I  regret  to  say  that  I  did  not  at  the  time  take  a  correct  view 
of  the  treatment,  or  precautions  necessary  to  be  adopted  under  such 
exigencies.  I  did  not  expect  that  the  case  would  terminate  fatally  in 
such  a  short  time,  and  I  anticipated  benefit  from  the  remedy  prescribed. 
He  was  ordered  to  take  the  tartar  emetic  solution  in  full  doses ;  but 
on  visiting  liim  next  morning,  we  found  that  he  had  obstinately  refused 
to  take  his  medicine,  and  that  his  symptoms  were  greatly  aggravated. 

In  delirium  of  this  kind  it  is  certainly  very  difficult  to  manage  the 
patient,  and  we  are  frequently  obliged  to  have  recourse  to  force  and 
stratagem  to  make  him  take  his  medicines.  I  regret  extremely  that 
this  man's  head  was  not  leeched  on  his  admission,  as,  from  the  state  of 
his  pulse,  I  tliink  he  would  have  borne  it  well.  Eight  leeches  might 
have  been  applied  to  his  temples,  and  repeated  two  or  three  times  the 
same  day,  according  to  the  state  of  his  pulse  and  strength.  I  think  I 
was  wrong  in  contenting  myself  with  ordering  the  tartar  emetic 
solution  and  a  blister  to  liis  head,  and  I  should  have  anticipated 
from  the  violence  of  his  behaviour  that  it  would  be  very  difficult  to 
manage  him. 

In  cases  of  this  kind,  where  it  is  necessary  to  give  tartar  emetic  (and 
this  is  one  of  the  best  remedies  you  can  employ  in  cases  of  cerebral 
excitement  in  fever),  you  should  be  always  prepared  to  obviate  any 
omission  arising  from  the  obstinacy  of  the  patient ;  and  when  he  will 
not  take  his  medicines  voluntarily,  you  may  secure  its  effects  on  the  sys- 
tem in  two  different  ways.  In  the  first  place,  it  may  be  secretly  mixed 
vdth  the  patient's  ordinary  drink ;  and  as  such  persons  are  generally 
thirsty,  and  seldom  refuse  drink  altogether,  an  intelligent  nurse  will 
readily  find  means  to  make  the  patient  take  a  sufficient  quantity  of  it  to 
secure  its  full  effect  on  the  cerebral  circulation. 


TAllTAR   EMETIC    IN    FEVER.  ]67 

Another  expedient  which  you  may  resort  to  in  similar  emergencies, 
is  to  give  the  tartar  emetic  in  the  form  of  enema.  I  had  recourse  to 
this  plan  sometime  since,  in  a  similar  case  of  delirium,  and  with  the 
best  results.  After  leeching  the  head  I  gave  the  solution  of  tartarised 
antimony  in  enema ;  and  this  can  be  always  done,  whether  the  patient 
likes  it  or  not,  if  you  take  care  to  prevent  his  struggles  by  confining 
him  in  a  strait  waistcoat.  The  best  way  of  administering  it,  is  to  dis- 
solve two  or  three  grains  of  tartar  emetic  in  four  or  five  ounces  of 
mucilage  of  starch  or  isinglass,  and  inject  it  with  the  aid  of  a  long 
flexible  tube,  so  as  to  make  the  contents  of  the  syringe  pass  high 
up  into  the  bowel.  In  this  way  you  can  secure  all  the  good  effects  of 
tartarised  antimony  in  overcoming  the  congestion  of  the  brain,, and 
procuring  sleep. 

In  all  cases  of  alarming  congestion  of  the  head  in  fever,  I  have  been 
long  in  the  habit  of  using  tartar  emetic  in  this  way,  if  the  stomach  be 
deranged,  and  incapable  of  bearing  it  safely  ;  and  I  can  assure  you  that 
it  is  a  most  fortunate  thing  to  have  such  a  powerful  resource  in  aU 
cases  of  the  kind.  I  have  also  not  unfrequently  given  expectorant 
medicines  in  the  same  way,  where  from  the  state  of  the  stomach,  or  the 
debihty  of  the  patient,  the  ordinary  remedies  could  not  be  administered 
by  the  mouth  with  sufficient  rapidity,  or  in  sufficient  quantity  to  pro- 
duce the  desired  effect.  In  this  manner  I  have  often  given  the  infusion 
of  ipecacuanha — a  remedy  of  very  considerable  value,  and  not  suffi- 
ciently appreciated  by  most  modern  practitioners.  I  may  also  remind 
you  that  vomiting,  and  all  the  benefits  derivable  from  it,  may  be  like- 
wise thus  produced.  Of  course  the  cases  in  which  these  expedients 
are  required  are  comparatively  rare,  but  the  practical  physician  must  be 
always  prepared  for  such  exigencies,  and  be  provided  with  means  of 
meeting  them. 

Another  of  our  patients  died  also  within  the  last  few  days  in  the 
fever  ward.  He  laboured  under  a  very  bad  form  of  maculated  fever, 
and  when  admitted  was  evidently  in  a  hopeless  state.  I  shall  not  say 
any  thing  about  this  case,  except  to  use  it  as  an  occasion  for  making  a 
few  observations  on  a  particular  state  of  the  cerebro- spinal  system, 
which  we  not  unfrequently  observe  in  cases  of  maculated  typhus,  and 
occasionally  in  other  varieties  of  fever.  Now  you  observed  that  this 
man  had  not  the  slightest  tendency  to  sleep ;  that  he  lay  with  liis  eyes 
constantly  open,  raved  incessantly,  had  subsultus  tendinum,  floccitatio, 
and  cold  extremities,  and  often  attempted  to  get  out  of  bed.  Yet  we 
ceuld  not  find  in  him  any  thing  like  decided  evidence  of  cerebral  inflam- 
mation. The  tunica  adnata  was  of  a  clear  pearl  white,  the  face  pale, 
and  the  scalp  and  integuments  of  the  face  cool.     You  perceive,  tlien. 


168  CLINICAL   MEDICINE. 

that  sleeplessness,  delirium,  and  subsultus  tendinum,  may  depend  on  a 
state  of  the  nervous  system  having  no  connexion  with  congestion  of  the 
brain,  or  determination  of  blood  to  the  head.  This  occurrence  has 
struck  me  very  forcibly  in  many  cases  of  fever.  But  I  have  been  most 
particularly  struck  with  the  occurrence  of  subsultus  tendinum  in  such 
instances.  In  the  present  case  we  had  a  patient  with  sleeplessness  and 
subsultus.     But  this  concurrence  of  symptoms  does  not  always  exist. 

You  recoUect  the  case  of  the  boy  in  the  small  fever  ward,  who  la- 
boured under  excessive  subsultus,  and  to  whom  we  gave  the  oil  of 
turpentine  in  drachm  doses  with  so  much  benefit.  Yet  this  boy,  as  you 
all  remember,  slept  remarkably  well.  I  have  frequently  pointed  out  to 
the  class,  patients  labouring  under  subsultus  tendinum,  who  slept  well, 
and  in  whom  the  tunica  adnata  was  of  a  pearl-white  colour,  without  the 
slightest  suffusion.  "We  have  subsultus,  therefore,  occurring  in  two  very 
opposite  states  of  the  nervous  system;  we  have  it  accompanied  by 
loss  of  sleep,  and  we  have  it  existing  in  that  condition  of  the  system 
where  the  patient  slumbers  long  and  heavily,  and  cannot  be  easily 
roused.  Hence  I  am  inclined  to  think  that  the  cause  of  subsultus  re- 
sides not  so  much  in  the  nervous  centres  as  in  their  extremities. 

I  would  even  go  so  far  as  to  advance  the  projBsition,  that  if  it  were 
possible  for  the  fever  to  go  on,  and  life  to  continue  after  the  removal  of 
the  brain  and  spinal  cord,  I  am  quite  sure  that  the  subsultus  would 
continue.  I  am  almost  confident  that  subsultus  tendinum  is  the 
result  of  some  derangement  of  the  nervous  extremities.  I  shall 
show  hereafter,  when  lecturing  on  the  subject  of  paralysis,  that  the 
nervous  periphery  may  become  diseased  primarily,  and  without  any  an- 
tecedent affection  of  the  brain  or  spinal  cord.  I  think  it  extremely  pro- 
bable that  in  fever  the  nervous  centres  are  subject  to  certain  derange- 
ments producing  coma,  sleeplessness,  and  delirium,  but  that  there  are 
other  nervous  symptoms  which  are  to  be  referred  rather  to  a  derange- 
ment of  the  nervous  extremities,  and  among  the  latter  I  would  particu- 
larly include  subsultus  tendinum,  a  symptom  which  we  find  coexisting 
with  such  opposite  conditions  of  the  nervous  centres. 

But  to  return  to  the  case  to  which  I  first  alluded.  Never  bhster  in 
the  early  stage  of  fever,  until  you  have  applied  leeches  in  sufficient  quan- 
tity. In  tliis  case,  it  is  true,  we  could  not  well  ascertain  what  the 
period  of  the  fever  was ;  for  the  man  was  brought  in  in  a  state  of  deli- 
rium, and  there  was  nothing  known  respecting  his  previous  history. 
Yet  you  are  all  aware  that  a  great  deal  must  depend  on  our  knowledge 
of  the  period  of  the  fever,  and  the  medicines  which  have  been  employed. 
Had  we  been  acquainted  with  these  circumstances,  it  is  probable  we 
Foujd  not  have  fallen  into  the  error  we  committed.     What  I  wish  to 


VOMITING   AND    DIARRHCEA    IN   THE    BEGINNING    OF    FEVER.  169 

impress  on  you  is,  that  in  all  cases  of  maculated  typhus,  you  should  be 
careful  in  examining  the  head  and  ascertaining  whether  there  are  any 
evidences  of  cerebral  congestion  present.  If  there  be  headache,  strong 
pulsation  of  the  carotids,  suffusion  of  the  eyes,  and  heat  of  the  face  and 
scalp,  along  with  the  other  signs  of  functional  lesion  of  the  brain  present, 
you  should  have  recourse  to  leeching ;  beginning  cautiously,  and  conti- 
nuing their  application  as  long  as  the  patient  will  bear  it  with  safety. 
When  you  have  the  symptoms  already  mentioned,  and  the  patient  is  in 
the  early  stage  of  fever,  you  may  commence  by  applying  one  or  two 
leeches  to  the  nostrils,  or  six  or  eight  to  the  temples,  or  behind  the 
ears,  repeating  them  two  or  three  times  a  day,  according  to  the  exigency 
of  the  case.  The  best  way  of  using  leeches  is  to  apply  them  in  small 
numbers  every  six  or  eight  hours,  so  as  to  keep  up  a  constant  drain 
from  the  head.  After  you  have  leeched  sufficiently,  you  may  then  have 
recourse  to  bhsters.  In  making  this  change  much  will  depend  on  the 
sagacity  and  skill  of  the  practitioner ;  for  it  requires  no  ordinary  tact  to 
hit  on  the  proper  time  when  you  should  give  up  leeching  and  commence 
with  bhsters. 

I  shall  make  no  apology  for  introducing  here  what  I  consider  to  be 
an  important  observation,  with  reference  to  the  pathology  and  treatment 
of  fever.  We  had  a  striking  instance  of  the  fact  on  which  I  am  about 
to  offer  some  comments,  in  the  case  of  a  Httle  girl  who  died  lately  here, 
in  a  very  remarkable  manner.  Every  fever  which  commences  with  vo- 
miting and  diarrhoea,  whether  it  be  scarlatina,  or  measles,  or  typhus,  is 
a  fever  of  a  threatening  aspect ;  and  in  all  such  fevers  the  practitioner 
should  be  constantly  on  the  watch,  and  pay  the  most  unremitting  at- 
tention to  the  state  of  the  brain.  There  is  much  difference  between  the 
vomiting  and  diarrhoea  of  gastro -enteritis  and  this  cerebral  diarrhaa 
and  vomiting.  The  latter  sets  in  generally  at  a  very  early  period  of  the 
disease,  perhaps  on  the  first  or  second  day,  and  is  seldom  accompanied 
by  the  red  and  furred  tongue,  the  bitter  taste  of  the  mouth,  the  burning 
thirst,  and  the  epigastric  tenderness,  which  belong  to  gastro-enteric 
inflammation. 

There  is  also  another  source  of  diagnosis,  but  of  a  less  valuable  kind ; 
and  this  is  founded  on  the  results  of  treatment.  Gastro-enteric  vomit- 
ing and  diarrhoea  are  reheved  by  leeching  the  belly ;  but  I  need  not  tell 
you  that  this  mode  of  treatment  can  have  no  effect  on  the  vomiting  and 
purging  produced  by  cerebral  disease.  There  is  also  another  means  of 
distinguishing :  the  vomiting  and  diarrhoea  which  result  from  gastro- 
enteric inflammation  are  never  accompanied  by  such  copious  discharges 
of  bile  as  when  they  depend  on  disease  of  the  brain.  In  diarrhoea  from 
derangement  of  the  brain,  the  quantity  of  bile  passed  is  very  remarkable; 


170  CLINICAL   MEDICINE. 

and  it  is  equally  curious,  that  when  vomiting  follows  derangement  of  the 
cerebral  circulation,  in  ordinary  cases,  and  without  fever,  bile  is  thrown 
up  in  very  large  quantities.  This  is  frequently  observed  in  persons  who 
become  sick  from  swinging  or  sailing.  In  such  instances,  a  larger 
quantity  of  bile  is  vomited  than  could  occur  from  mere  gastric  irritation. 

Now,  in  the  commencement  of  cerebral  disease,  where  congestion  or 
inflammation  is  present,  one  of  the  first  symptoms  is  copious  vomiting 
and  purging  of  a  bilious  character.  This  is  very  often  the  case  in  scar- 
latina, and  there  are  few  cases  in  wliich  there  is  more  danger  to  be  ap- 
prehended. We  had  these  symptoms,  under  very  unfavourable  circum- 
stances in  the  httle  girl  to  whom  I  have  just  alluded.  From  the  imper- 
fect history  of  the  case  which  we  were  able  to  obtain,  it  appeared  that 
she  had  been  ill  of  fever  for  fourteen  days  before  her  admission,  and  had 
in  addition  a  severe  attack  of  bronchitis  and  pneumonia.  She  then  got 
inflammation  of  the  stomach,  and  finally  congestion  of  the  brain,  as  in- 
dicated by  the  cerebral  vomiting  and  purging.  We  employed  every 
means  in  our  power  to  check  these  symptoms,  but  without  success ;  she 
went  on  from  bad  to  worse,  and  she  ultimately  sank  under  a  combina- 
tion of  affections,  wliich  you  will  frequently  observe  in  many  forms  of 
disease  as  well  as  fever ;  and  it  is  to  this  point  in  particular  that  I  msh 
to  direct  your  attention. 

You  will  frequently  observe  that  at  a  certain  period  of  fever,  whether 
it  be  inflammatory,  nervous,  bilious,  or  typhoid, — and  very  often  in 
other  forms  of  disease,  whether  depending  on  a  general  affection  of  the 
system,  or  connected  with  inflammation  of  important  organs,  when  the 
patient  has  been  going  on  pretty  well  for  some  time, — you  will  flnd  that 
about  the  period  when  you  would  naturally  expect  the  fever  to  go  off, 
and  convalescence  begin,  a  new  form  of  fever  makes  its  appearance,  and 
carries  off  the  patient  in  spite  of  aU  your  exertions.  To  this  form  of 
secondary  fever  I  would  give  the  name  of  scrofulous,  because  it  resem- 
bles in  its  chief  features  the  intractable  form  of  fever  wliich  is  frequently 
observed  in  persons  of  an  originally  scrofulous  habit,  or  who  have  be- 
come so  from  the  abuse  of  mercury  or  other  debiHtating  causes. 

This  is  a  subject  which  is  not  well  understood,  and  I  am  not  ac- 
quainted with  any  author  who  has  devoted  to  it  that  share  of  attention 
to  which,  from  its  great  importance,  it  has  such  decided  claims.  Its 
chief  characters  are,  that  the  patient,  during  its  existence,  exlubits  a 
strong  tendency  to  inflammatory  affections,  which  bear  a  close  analogy 
to  the  scrofulous,  both  in  their  intractable  character,  in  the  facihty  with 
which  they  pass  from  one  organ  to  another,  and  in  their  frequently  un- 
favourable termination.  A  patient  of  this  description,  while  labouring 
under  fever,  will  frequently  exhibit  a  very  remarkable  succession  of  in- 


SCEOFULOUS  SECONDARY  t'EVEll.  171 

flammatory  affections.  If,  during  the  course  of  his  fever,  he  gets  an 
attack  of  gastro -enteritis,  you  will  have  great  difficulty  in  managing  it ; 
and  no  sooner  is  this  overcome,  than  he  is  seized  with  bronchitis  or  pneu- 
monia ;  and  when,  by  great  care  and  the  most  skilful  treatment,  you 
have  overcome  this  also,  he  gets  scrofulous  inflammation  of  the  brain, 
and  dies. 

Now  you  will  frequently  meet  with  patients  who,  during  the  course 
of  typhus,  will  be  attacked  with  this  bad  form  of  fever,  and  get  what 
may  be  termed  scrofulous  inflammation  of  the  brain,  which  carries  them 
off  in  five  or  six  days,  jn  spite  of  aU  your  care.  You  are  aware  that 
persons  who  are  much  in  the  habit  of  observing  diseases  of  the  brain, 
can  generally  distinguish  between  scrofulous  inflammation  of  the  brain 
and  its  membranes  and  that  inflammation  which  occurs  in  persons  of 
healthy  habit.  In  cases  of  the  latter  description,  the  treatment,  if  com- 
menced at  the  first  appearance  of  the  disease,  is  simple  and  successful. 
Appropriate  bleeding  and  leeching,  with  the  use  of  calomel  and  James's 
powder,  are  almost  always  sufficient  to  accomplish  a  cure.  When  once 
you  have  succeeded  in  touching  the  gums  with  mercury,  the  patient's 
safety  is  tolerably  certain,  and  recovery  is  in  general  rapid.  Rut  in 
the  scrofulous  affections  of  the  brain,  although  you  may  have  fully  mer- 
curialised your  patient,  you  will  too  often  discover  that  you  have  merely 
retarded  the  progress  of  the  complaint  for  a  brief  period  ;  it  grows  bad 
again,  and  carries  him  off  in  spite  of  aU  your  efforts. 

In  the  scrofulous  hydrocephalus,  a  much  greater  time  elapses  from 
the  appearance  of  coma  and  strabismus  until  death  takes  place,  than  in 
the  ordinary  forms  of  meningitis.  This  fact  was  well  illustrated  in  the 
case  of  the  girl  to  which  I  have  just  now  referred  :  she  continued  to 
live  on  for  a  long  time  after  the  appearance  of  symptoms,  which  you 
would  think  ought  to  terminate  fatally  in  a  few  hours  after  they  had 
been  developed.  There  is  also  a  great  deal  of  irregularity  in  the  ■  way 
the  symptoms  come  on  in  cases  of  scrofulous  inflammation  of  the  brain. 
Sometimes  bhndness  is  one  of  the  first  symptoms.  I  recollect  having 
been  called,  with  Dr.  Beatty,  to  see  a  very  fine  boy,  living  in  Merrion- 
square,  and  was  very  much  struck,  on  entering  the  drawing-room,  to 
find  him  walking  about,  and  in  apparent  good  health,  but  quite  blind. 
Here  amaurosis  was  the  first  symptom.  This  was  subsequently  suc- 
ceeded by  others,  and  he  died  in  a  convulsive  fit  about  a  fortnight  after- 
wards. 

"We  have  many  excellent  observations  on  the  chronic  scrofulous  fever, 
but  I  think  that  there  is  no  author  who  has  described  this  acute  form 
with  the  precision  and  care  which  it  deserves.  It  is,  however,  a  very 
frequent  form  of  fever,  and  you  wiU  see  many  examples  of '  it  among  the 


172  CLINICAL   MEDICINE. 

chronic  patients  in  the  medical  and  surgical  wards.  You  will  fre- 
quently observe  persons  who  are  labouring  under  acute  disease^  from 
accidents  or  other  causes^  become  feverish  and  ill  again  at  a  time  when 
you  expected  a  remission  of  their  symptoms,  or  even  recovery ;  and 
without  any  assignable  cause,  they  will  get  scrofulous  inflammation  of 
some  other  part  or  organ,  and  quickly  fall  into  a  state  of  hopeless  and 
incurable  disease. 


I 


173 


LECTURE  XIV. 


HEAD  SYMPTOMS  IN  FEVEE. 


I  spoke  at  my  last  Lecture  of  a  man  named  Cassels,  who  died  in  the 
fever  ward  with  symptoms  of  cerebral  excitement,  and  stated  that  I  re- 
gretted having  omitted  to  leech  his  head,  and  prescribe  tartar  emetic  in 
the  form  of  enema.  Since  that  time  we  have  had  an  opportunity  of  ex- 
amining his  body,  and  the  results  of  the  dissection  are  well  worthy  your 
attentive  consideration.  He  was  a  young  man  of  robust  habit  and  ap- 
parently good  constitution,  and  laboured  under  the  ordinary  form  of 
maculated  typhus.  Shortly  after  his  admission  he  was  attacked  with 
delirium,  which  was  soon  afterwards  followed  by  coma  and  death. 

Now,  suppose  you  were  called  to  see  a  patient,  not  labouring  under 
typhus,  but  exhibiting  a  similar  train  of  symptoms — that  is  to  say, 
violent  delirium,  accompanied  by  flushing  of  the  face,  suffusion  of  the 
eyes,  headache,  and  a  tendency  to  get  out  of  bed — in  fact,  a  state  of 
furious  excitement  requiring  the  restraint  of  the  strait  waistcoat — 
what  idea  would  you  be  likely  to  form  of  the  condition  of  the  brain  ? 
If  a  patient  of  this  kind  had  no  typhoid  symptoms,  you  would  certainly 
say  that  he  was  labouring  under  meningitis  or  cerebritis ;  and  if  the 
case  proved  fatal,  you  would  naturally  expect  to  find  lesions  of  the  brain 
fully  sufficient  to  account  for  all  his  symptoms.  And  you  would  in  aU 
probability  find  extensive  thickening  of  the  membranes  of  the  brain, 
with  sub-arachnoid  effusion,  or  you  would  discover  softening,  increased 
vascularity,  and  suppuration  of  the  encephalic  mass. 

But,  here,  a  man  in  fever  exhibits  aU  the  symptoms  of  cerebral  in- 
flammation ;  the  cerebral  affection  runs  on  to  a  fatal  termination  mth 
great  rapidity ;  he  dies  comatose.  And  what  do  we  find  on  dissection  ? 
Doubtful  signs  of  congestion,  and  no  distinct  evidence  of  inflammation; 
a  slight  opacity  of  the  arachnoid  at  the  base  of  the  brain,  and  about  a 
teaspoonful  of  clear  sub-arachnoid  effusion.  Now  this  is  a  point  to 
which  I  would  earnestly  call  the  attention  of  every  inquiring  student. 


174  CLINICAL   MEDICINE. 

A  patient,  during  the  course  of  typhus,  is  seized  with  symptoms  which 
are  generally  regarded  as  characteristic  of  congestion  and  inflammation 
of  the  brain ;  he  dies,  to  all  appearance  in  consequence  of  the  intensity 
and  violence  of  these  symptoms,  and  on  dissection  little  or  no  trace  of 
cerebral  disease  is  found.  In  the  case  under  consideration,  the  symp- 
toms present  were  strongly  indicative  of  congestion  if  not  of  inflam- 
mation ;  and  had  the  man  been  free  from  typhoid  symptoms,  you  would 
expect  to  find  decided  traces  of  inflammatory  mischief.  This  seems  to 
prove  that  in  the  production  of  cerebral  symptoms  in  typhus,  some 
cause  not  to  be  recognised  by  the  production  of  cerebral  lesions,  or  in 
other  words  something  besides  mere  congestion  or  inflammation  exists. 
I  have  now  examined  a  great  number  of  cases  of  this  description,  and 
the  examination  has  brought  home  to  me  a  strong  conviction,  that  the 
delirium  of  fever  depends  upon  something  more  than  mere  inflamma- 
tion or  congestion. 

There  is  another  fact,  the  study  of  which  is  well  worthy  of  attention, 
as  it  appears  to  support  very  strongly  the  views  I  have  put  forward ; 
and  that  is  the  occurrence  of  analogous  symptoms  under  opposite  con- 
ditions of  the  cerebral  circulation.  Take,  for  example,  the  phenomena 
of  vertigo  and  headache.  Now  these  symptoms  are  found  in  states  of 
the  brain  which  are  directly  opposite.  In  incipient  congestion  of  the 
brain,  in  that  turgescence  of  the  cerebral  vessels  which  precedes  apo- 
plectic seizures,  one  of  the  most  frequent  symptoms  is  vertigo,  and  the 
same  thing  may  be  afiirmed  with  respect  to  headache.  But  we  observe 
the  very  same  symptoms  under  circumstances  totally  dissimilar.  Fre- 
quently while  bleeding  a  patient  for  some  affection  of  the  lungs  or 
bowels,  or  for  some  accident,  we  find  that  after  a  certain  quantity  of 
blood  has  been  lost,  the  patient  becomes  pale ;  and  while  the  pallor  is 
coming  on,  he  often  gets  quite  giddy,  and  sometimes  complains  of  head- 
ache. Gentlemen  who  are  attending  lying-in  hospitals  are  well  acquain- 
ted with  the  headache,  giddiness,  and  tinnitus  aurium,  so  constantly  com- 
plained of  by  females  who  have  suffered  from  excessive  uterine  he- 
morrhage. 

Hence  you  perceive  facts  are  not  wanting  to  show  that  opposite  states 
of  the  cerebral  circulation,  a  superabundance  or  deficiency  of  pressure 
on  the  brain,  may  give  rise  to  similar  phenomena.  You  saw  an  illus- 
tration of  this  in  the  case  of  one  of  our  patients  in  the  fever  ward  this 
morning.  He  was  quite  free  from  headache  as  long  as  he  remained  in 
the  horizontal  posture,  but  the  moment  he  sat  np  in  bed  lie  complained 
of  headache.  Yet  this  was  a  man  who  had  not  the  slightest  symptom 
of  determination  to  the  head,  and  who  had  been  sufficiently  depleted 
during  his  illness.     You  will  also  recollect  the  fact,  that  persons  who 


HEAD  SYMPTOMS  IN  FEVER.  175 

have  had  a  long  illness,  and  remained  for  many  days  in  the  horizontal 
posture,  generally  get  weakness,  giddiness,  and  sometimes  headache, 
when  they  first  attempt  to  sit  up  during  convalescence. 

This  is  a  point  which  should  be  always  borne  in  mind.  You  are  con- 
sulted by  one  person  who  complains  of  giddiness,  tinnitus  aurium,  and 
frequently  recurring  headache.  You  examine  the  patient  carefully,  and 
you  find  aU  the  symptoms  of  unequivocal  determination  to  the  head. 
You  are  applied  to  by  another  person  labouring  under  the  same  symp- 
toms ;  but  how  different  is  the  state  of  the  brain  found  to  be  on  a 
careful  examination.  One  patient  is  robust,  of  florid  complexion,  and 
with  a  hard  bounding  pulse ;  the  other  is  a  weak  chlorotic  female,  who 
has  been  ailing  for  months,  and  whose  pulse  is  so  weak,  that  a 
slight  degree  of  pressure  obliterates  the  canal  of  the  artery.  Yet 
the  tinnitus  aurium,  giddiness,  and  headache,  complained  of  by  the 
latter,  are  just  as  bad  and  as  troublesome  as  in  the  case  of  the 
former. 

Trom  a  consideration  of  these  points,  you  will  perceive  that,  for  the 
production  of  cerebral  symptoms  in  typhus,  there  must  be  something 
more  than  mere  congestion  or  inflammation  of  the  brain ;  but  you 
are  not  to  infer  from  this  that  there  is  no  necessity  for  taking  any 
steps  to  obviate  or  remove  congestion  of  the  head  in  fever.  On 
the  contrary,  I  am  of  opinion  that  in  typhus  one  of  the  principal 
sources  of  danger  is  connected  with  the  head,  and  that  the  cerebral 
symptoms  should  be  always  watched  with  the  most  unremitting  and 
anxious  attention. 

It  is  this  which  constitutes  the  great  difference  between  the  mortality 
in  private  and  hospital  practice.  In  private  practice  the  physician  is 
called  at  an  early  period  of  the  disease,  and  has  anopportunity  of  check- 
ing the  cerebral  symptoms  before  they  rise  to  a  dangerous  height ;  but 
hospital  patients,  in  general,  are  admitted  at  an  advanced  stage  of  fever, 
and  in  many  instances  have  been  improperly  treated,  or  wholly  neglected 
from  the  commencement.  I  am  also  of  opinion,  that  when  there  is 
any  evidence  of  determination  to  the  head,  the  best  way  of  preventing 
dangerous  cerebral  symptoms  is  to  deplete  the  head  by  the  application 
of  a  sufficient  number  of  leeches,  and  then  to  proceed  to  the  use  of 
blisters.  You  should  direct  your  attention  as  much  to  the  head  as  to 
the  bowels,  and  one  of  the  best  modes  of  doing  tliis  is  to  apply  six  or 
eight  leeches  behind  the  ears,  and  repeat  them  every  six  hours  until  re- 
lief is  obtained.  You  should  then  order  the  head  to  be  shaved,  and 
kept  constantly  covered  with  cloths  wet  with  warm  vinegar  and  water, 
and  at  the  same  time  have  recourse  to  the  internal  use  of  tartar 
emetic  and  nitre,  or  blue  piU  with  James's  powder.     Should  this  plan 


176  CLINICAL   MEDICINE. 

fail  in  giving  relief,  you  have  a  powerful  aid  in  the  application 
of  bhsters  to  the  scalp,  and  this  must  be  done  extensively,  and  at 
once. 

Most  of  the  fatal  cases  of  typhus  at  present  die  of  cerebral  disease ; 
but  in  the  majority  of  instances  you  will  find  that  these  were  cases  in 
which  the  head  was  neglected,  and  in  which  the  appropriate  remedies 
were  used  too  late.  In  cases  treated  from  the  commencement  with 
judgment,  decision,  and  attention,  although  the  head  may  be  threatened, 
you  will  not  have  one -twentieth  of  the  mortality  observed  in  cases  where 
the  early  prevention  of  cerebral  symptoms  has  not  been  an  object  of 
care.  One  of  the  worst  cases  of  cerebral  disease  which  I  have  wit- 
nessed for  many  months,  and  which  would  have  probably  terminated 
fatally  before  the  seventh  day,  I  saw  in  consultation  with  the  late 
Mr.  Daly,  and  yet  this  case  was  saved  by  prompt  and  decided  measures 
calculated  to  counteract  the  cerebral  symptoms. 

I  have  also  very  recently  witnessed  another  remarkable  case  of  this 
description  at  Bray.  The  patient,  a  gentleman  very  fuU  and  plethoric, 
but  remarkably  temperate,  aged  thirty-five,  was  attacked  after  exposure 
to  cold  by  intensely  violent  maculated  fever,  for  which  aperients  of  an 
active  nature  were  exhibited.  I  saw  him  in  consultation  with  Dr. 
Hefi'ernan  on  the  6th  day.  His  headache  had  been  relieved  by  leeching, 
but  his  breathing  was  very  quick,  and  he  was  almost  constantly  asleep. 
Skin  very  hot ;  eyes  somewhat  suffused ;  most  copious  crop  of  maculae. 
We  at  once  blistered  the  whole  scalp ;  and  on  the  eight  day  blistered  it 
again,  and  also  the  nape.  On  the  ninth  day  the  cerebral  symptoms, 
which  we  had  been  endeavouring  to  anticipate,  came  on,  but  probably 
our  treatment  prevented  them  from  being  fatal ;  for  when  they  appeared, 
the  application  of  tartar  emetic  ointment  induced  a  purulent  discharge 
from  the  whole  surface  of  the  twice  blistered  scalp,  in  the  course  of  a 
few  hours,  and  three  grains  of  tartar  emetic  given  in  divided  doses  that 
day  procured  a  complete  cessation  of  the  symptoms,  after — ^mark,  after 
the  pupils  had  been  dilated,  and  one  fit  of  slight  paralysis  of  the 
mouth  and  tongue  had  taken  place. 

The  result  of  all  my  experience  in  fever  is,  that  the  majority  of  fatal 
cases  are  rendered  so,  in  this  country  at  least,  by  severe  cerebral  symp-w 
toms  supervening  sooner  or  later  in  the  disease.  Delirium,  sleepless- 
ness, stupor,  convulsions,  extreme  subsultus,  jactitation,  sluggish  and 
dilated,  or  else  extremely  contracted,  pupils  :  these  are  the  symptoms 
we  have  to  fear  after  the  fever  has  lasted  some  time  ;  and  let  me  repeat 
it,  the  chief  art  of  the  physician  consists  not  so  much  in  remedying 
these  symptoms  as  in  anticipating  them.  When  he  judiciously  attempts 
this,  he  may  not,  indeed,  always  succeed  in  preventing  their  superven- 


HEAD    SYMPTOMS    IN    FEVEIl.  177 

tion,  but  he  will,  in  many  cases,  be  successful  in  diminisliing  their 
violence,  and  preventing  their  usually  disastrous  effects. 

Permit  me  next  to  direct  your  attention  to  the  case  of  the  patient 
Murphy,  who  died  last  week.  This  case  excited  a  good  deal  of  our 
attention  at  the  time,  and  I  wish  to  make  some  further  observations  on 
it  while  it  remains  fresh  in  your  minds. 

It  was  one  of  those  mixed  cases  of  typhus,  in  which,  as  the  fever 
advances,  we  observe  the  usual  phenomena  of  determination  to  the 
head,  accompanied  by  a  train  of  symptoms  which  bear  a  close  analogy 
to  those  of  delirium  tremens.  Among  the  pauper  population  which  we 
have  to  treat,  you  will  frequently  meet  with  cases  of  tliis  description. 
We  witnessed  many  examples  of  it  here,  but  not  so  many  as  are  to  be 
seen  in  other  hospitals.  It  is  a  melancholy  but  well-known  fact,  that  a 
great  proportion  of  the  diseases  which  come  under  our  notice,  in  the 
acute  as  well  as  in  the  chronic  form,  are  more  or  less  complicated  with 
intemperance.^  This  you  should  never  forget.  In  persons  of  the 
lower  class,  who  are  addicted  to  the  daily  use  of  spirituous  liquors,  you 
will  find  disease  assuming  a  thousand  unfavourable  shapes  and  compli- 
cations. You  will  find  their  fevers  intermixed  with  various  symptoms 
of  an  anomalous  or  dangerous  character,  and  their  chronic  affections 
embarrassed  by  organic  and  visceral  disease.  You  will  be  repeatedly 
struck  with  the  strange  and  protean  character  which  disease  assumes 
under  the  influence  of  an  habitual  intemperance ;  and  you  will  often,  in 
the  course  of  your  practice,  have  to  endure  the  annoyance  and  disap- 
pointment of  seeing  your  patient  carried  off  by  some  new  and  unexpected 
malady,  after  you  have  succeeded,  by  infinite  toil,  ingenuity,  and  patience, 
in  removing  every  trace  of  his  primary  affection. 

The  case  of  Mui'phy  was  one  of  those  which  have  been  neglected  in 
the  beginning,  where  the  vantage  ground  has  been  lost,  and  the 
chances  of  success  are  diminished  almost  to  nothing.  You  have 
observed  that  all  the  fatal  cases  of  fever  which  we  have  had  in  hospital 
were  cases  admitted  at  an  advanced  period  of  the  disease,  and  in  which 
the  head  had  been  neglected.  You  have  also  observed  how  exceedingly 
difficult  it  must  be  to  treat  cases  of  this  description.  The  patient  is 
admitted  at  an  advanced  stage  of  fever,  and  at  a  period  when  he  can 
give  no  account  of  his  present  or  past  symptoms,  or  the  mode  of  treat- 
ment to  which  he  has  been  submitted.  He  comes  in  with  delirium,  or 
coma,  and  subsultus  tendinum ;  his  symptoms  are  certainly  cerebral, 
and  he  exhibits,  perhaps,  a  blistered  scalp ;  but  we  can  have  no  means 

*  Since  this  lecture  was  delivered,  a  great  change  for  the  better  has  been  effected  by  the 
efforts  of  the  Rev.  Mr.  Matthew — the  poorer  and  working  classes  of  Ireland  are  now  for 
the  most  part  distinguished  for  temperance. 

VOL.  I.  ,13 


178  CLINICAL   MEDICINE. 

of  ascertaining  whether  he  has  had  headache,  heat  of  scalp,  throbbing 
of  the  carotid  and  temporal  arteries,  or  vertigo, — we  cannot,  in  fact, 
decide  with  precision  as  to  the  exact  state  of  the  brain,  and  our  practice 
must  be  embarrassed  by  more  or  less  doubt  and  obscurity.  I  have 
already  impressed  upon  your  attention  the  urgent  necessity  of  watcliing 
the  head  in  fever,  and  I  think  I  caimot  too  often  reiterate  the  advice 
which  I  have  given  you,  to  endeavour  to  check  cerebral  symptoms  before 
they  amount  to  any  degree  of  absolute  danger.  The  fate  of  those  who 
have  died  here  will  convince  you  that  when  cerebral  disease  has  once 
arrived  at  its  acme,  the  most  energetic  measures  will  often  fail  in 
arresting  it.  It  is  a  matter  of  vital  importance,  then,  to  prevent  tliis 
lamentable  state  of  things,  and,  as  I  have  already  remarked  in  this 
lecture,  without  waiting  until  the  symptoms  of  cerebral  disease  manifest 
themselves,  to  anticipate  its  very  origin,  and  thus  be  enabled  to  control 
with  certainty,  symptoms  which  assume  such  a  fearful  aspect  in  cases, 
where  cerebral  disease  has  been  allowed  to  go  on  unregarded.  Tliis  is 
the  practical  lesson  which  I  wish  you  to  draw  from  the  four  fatal 
cases  which  have  occurred  in  this  hospital  within  the  last  month. 

There  are  some  points  in  the  case  of  Murphy  to  wliich  I  wish  to 
recal  your  attention,  as  I  am  anxious  that  you  should  make  them  the 
subject  of  reflection.  Tor  some  days  before  his  death,  he  had  been  deli- 
rious and  unmanageable,  wdth  total  loss  of  sleep,  and  a  contracted  state 
of  the  pupil.  The  antiphlogistic  and  derivative  treatment  had  been 
employed  without  efiect ;  and  seeing  that  his  symptoms  were  advancing, 
and  his  sleeplessness  undiminished,  I  ventured  to  give  him  an  injection, 
consisting  of  two  grains  of  tartar  emetic  with  ten  drops  of  laudanum. 
I  am  cautious  in  the  administration  of  opium  in  the  advanced  stage  of 
fever,  where  there  is  evidence  of  determination  to  the  head ;  and  it  was 
on  this  account  that  I  ordered  it  to  be  combined  with  tartar  emetic, 
giving  also  directions  that  the  effect  of  each  dose  should  be  carefully 
watched.  He  got  three  enemata  during  the  course  of  the  night — that 
is,  thirty  drops  of  laudanum  altogether.  He  dozed  after  the  last  injection, 
and  appeared  more  tranquil ;  but  at  our  morning  visit  we  found  him  in 
a  state  of  coma,  with  rapid  sinking  of  the  powers  of  life,  and  death  took 
place  in  the  course  of  a  few  hours  afterwards.  I  must  confess  the  issue 
of  the  case  gave  me  some  degree  of  uneasiness  at  the  time,  as  I  thought 
it  might  have  been  precipitated  by  the  administration  of  the  opium.  I 
could  not  say  but  that  even  this  small  quantity  of  opium  might  have 
greatly  aggravated  the  cerebral  symptoms,  and  accelerated  the  fatal  event. 

Dissection,  however,  revealed  the  true  cause  of  death.  On  opening 
the  brain,  we  found  extensive  arachnoid  inflammation,  some  effusion  on 
the  surface  of  the  brain,  and  an  intensely  congested  state  of  its  vessels. 


HEAD    SYMPTOMS    IN    FEVER.  179 

The  patient,  altogether  dissipated  in  his  habits,  and  greatly  reduced  by 
fever,  had  been  a  young  man  of  rather  robust  constitution  previous  to 
his  illness ;  he  had  been  neglected  in  the  beginning  of  his  fever,  which, 
from  the  phenomena  observed  after  death,  must  have  been  characterised 
by  early  and  decided  determination  to  the  brain,  producing  delirium, 
watchfulness,  coma,  and  a  contracted  state  of  the  pupil,  which  all  our 
antiphlogistic  measures  were  inadequate  to  remove  or  control.  We  did 
every  thing  in  our  power :  we  leeched,  blistered,  and  gave  tartar  emetic, 
but  without  effect ;  the  case  had  not  come  under  our  care  until  symptoms 
of  unmanageable  cerebral  disease  had  been  established. 

This  state  of  delirium,  followed  by  contraction  of  the  pupil  and  coma, 
and  terminating  in  death,  occurs  in  two  classes  of  cases;  first,  in 
hospital  patients  of  the  lower  class,  who  have  been  neglected  in  the 
commencement  of  fever ;  and  secondly,  in  persons  in  the  better  classes 
of  life,  in  whom  the  mind  is  frequently  subjected  to  over-exertion,  and 
who,  when  attacked  by  fever,  exhibit  a  strong  tendency  to  the  early 
development  of  cerebral  symptoms  of  a  bad  and  unmanageable  character. 
One  of  the  worst  symptoms  observed  in  such  cases  is  extreme  contraction 
of  the  pupil.  I  have  seen  the  pupil  in  some  cases  contracted  to  the 
size  of  a  pin-hole ;  and  I  think  I  can  state,  that  out  of  all  the  cases  of 
this  description  which  I  have  witnessed,  there  were  but  two  recoveries. 
I  have  seen  persons  who  had  exceedingly  bad  and  alarming  symptoms 
of  cerebral  derangement  recover,  although  accompanied  by  great  dila- 
tation of  pupil ;  but  I  think  I  have  seen  but  two  cases  recover  in 
which  the  pupil  was  contracted  to  the  small  size  observed  in  Murphy. 

With  these  facts  fresh  in  your  minds,  allow  me  to  direct  your  attention 
to  the  case  of  another  man,  who  died  lately  in  the  fever  ward  with 
cerebral  symptoms  of  an  intense  character.  Now,  in  this  man  the  very 
same  train  of  phenomena  were  present  which  we  observed  in  Murphy's 
case.  He  had,  you  recollect,  typhus  of  a  low  character,  accompanied 
by  delirium,  subsultus,  and  the  ordinary  symptoms  of  determination  to 
the  head.  I  defy  any  man  who  compared  these  two  cases  together  to 
point  out  any  remarkable  difference  between  them.  The  delirium, 
nervous  excitement,  and  watchfulness,  commenced  the  same  way  in 
both,  and  ran  through  the  same  course ;  both  had  contraction  of  the 
pupil,  constant  muttering  and  delirium,  persistent  watchfulness,  and 
subsultus  tendinum ;  and  in  both  the  cerebral  symptoms  terminated  in 
coma  and  death.  I  would  defy  the  most  accurate  symptomatologist  to 
point  out  any  marked  distinction  between  them.  Yet  how  different 
were  the  phenomena  observed  on  dissection !  In  the  one  there  was 
extensive  lesion  of  the  membranes  of  the  brain,  effusion  on  its  surface, 
and  intense  congestion  of  its  vessels  ;  in  the  other,  there  was  no  appre- 


180  CLINICAL    MEDICINE. 

ciable  departure  from  the  normal  condition.  But  it  is  not  in  typhus 
alone  that  we  meet  with  the  occurrence  of  analogous  symptoms  in 
cases,  which  exhibit  a  very  different  state  of  the  brain  after  death.  We 
are  encountered  with  the  same  puzzling  contrarieties  in  many  cases  of 
scarlatina.  Cases  come  under  our  notice  in  wliich  the  patients  appear 
to  die  entirely  from  the  violence  of  the  cerebral  symptoms,  and  yet,  on 
examination,  we  find  very  dissimilar  states  of  the  brain.  In  some,  there 
is  palpable  and  fatal  lesion — in  others,  there  are  some  dubious  marks  of 
congestion,  quite  insufficient  to  account  for  the  symptoms ;  or  the  brain 
is  found  to  be  perfectly  sound  and  normal. 

It  would  appear  that  in  scarlatina  and  fever,  the  poison  of  the  disease 
exercises  a  deleterious  influence  on  the  brain,  independently  of  inflam- 
mation, but  capable  of  producing  an  analogous  train  of  symptoms. 
Hence  it  is  in  many  instances  extremely  difficult  to  distinguish  the 
cerebral  symptoms  produced  by  the  poisonous  influence  of  fever  on  the 
brain,  from  those  which  depend  on  true  inflammation.  The  one  gives 
rise  to  delirium  and  fatal  coma  as  well  as  the  other;  and  in  the 
advanced  stage  of  fever,  when  the  manifestations  of  nervous  energy  are 
feeble  and  imperfect,  and  when  the  circulating  and  respiratory  organs 
act  with  diminished  power,  the  distinction  between  mere  irritation  and 
actual  inflammation  becomes  a  matter  of  great  difficulty. 

In  alluding  to  the  occurrence  of  analogous  symptoms  under  opposite 
conditions  of  the  brain,  I  noticed  that  headache,  tinnitus  aurium,  and 
giddiness,  have  been  observed  in  cases  where  there  was  distinct  evidence 
of  determination  to  the  head,  as  well  as  where  there  was  every  reason  to 
believe  that  the  supply  of  blood  to  the  brain  was  greatly  diminished. 
You  wiU  find  a  very  curious  illustration  of  this  fact  in  the  first  volume 
of  Guy's  Hospital  Reports,  which  contains  a  very  interesting  paper 
from  Sir  Astley  Cooper,  on  the  effects  produced  by  tying  the  carotid  and 
vertebral  arteries.  Among  other  results,  it  appears  that  when  the 
supply  of  arterial  blood  destined  for  the  brain  is  diminished,  the  animal 
experimented  on  becomes  stupid,  is  to  a  certain  extent  incapable  of 
voluntary  motion,  and  exhibits  a  very  remarkable  dilatation  of  the 
pupils.  This  is  an  extremely  curious  fact.  You  are  all  aware  that 
dilatation  of  the  pupils  has  been  long  regarded  as  one  of  the  most 
characteristic  signs  of  extravasation  and  increased  pressure  on  the  brain ; 
and  yet  it  appears,  the  very  same  condition  of  the  pupil  is  observed 
when  you  cut  off  the  supply  of  arterial  blood  to  the  brain.  We  are, 
I  fear,  as  yet  very  much  in  the  dark  as  to  the  derangement  of  function 
which  occurs  in  the  brain  under  opposite  states  of  its  vessels ;  and  I 
think  we  have  equally  imperfect  and  confused  notions  of  the  changes 
which  take  place  in  that  organ  as  the  result  of  fever. 


HEAD    SYMPTOMS    IN    FEVER.  181 

Dilatation  of  the  pupils  is  usually  regarded  as  a  sign  of  increased 
pressure  on  the  brain ;  and  when  hydrocephalic  symptoms  are  present, 
it  is  generally  looked  upon  as  pathognomonic  of  effusion.  Yet  from  the 
experiment  just  alluded  to,  we  find  that  dilatation  of  the  pupil  is  also 
the  result  of  a  state  of  things  in  which  we  cannot  suppose  the  existence 
of  any  thing  like  increased  pressure  on  the  brain.  When  I  speak  of 
increased  or  diminished  pressure  on  the  brain,  I  am  not  prepared  to 
maintain  that  such  is  actually  the  case,  or  that  when  a  man  becomes 
giddy  and  faints  after  bleeding,  the  actual  quantity  of  blood  circulating 
in  the  brain  is  diminished,  and  consequently  the  amount  of  pressure ; 
but  when  a  man  gets  headache,  vertigo,  or  syncope,  from  the  loss  of 
blood,  it  must  depend  upon  causes  different  from  those  which  are  con- 
nected with  congestion  of  the  brain,  or  extravasation  on  its  surface,  or 
into  its  substance.  AVhat  I  wish  to  impress  upon  your  minds  is,  that 
dilatation  of  the  pupils  may  be  connected  with  very  opposite  states  of 
the  cerebral  circulation ;  and  that  in  fever  it  cannot  of  itself  be  regarded 
as  a  sign  of  paramount  value  in  determining  the  existence  of  congestion 
or  inflammation  of  the  brain. 

It  may  not  be  amiss  to  mention  briefly  on  the  present  occasion,  the 
details  of  a  very  remarkable  communication,  by  Surgeon  Eussel,  of  the 
73rd  regiment,  formerly  a  pupil  in  this  hospital.  This  communication 
was  read  by  Dr.  Wilson,  at  one  of  the  soirees  of  the  College  of  Physi- 
cians in  London,  and  afterwards  published  in  the  Medical  Gazette. 
Mr.  Eussel  observes — 

''  I  was  led,  by  the  following  circumstance,  to  reflect  on  the  nature  of 
coup  de  soleil ;  which  as  well  as  I  can  recollect,  is  treated  of  by  all 
authors,  and  is  generally  considered  to  be  nothing  more  or  less  than 
true  apoplexy,  produced  by  the  direct  influence  of  the  sun's  rays ;  that 
its  pathology  is  the  same,  and  its  mode  of  treatment  similar — that  is, 
that  all  the  efforts  of  the  medical  attendant  should  be  directed  to  the 
head,  as  the  chief,  nay,  almost  the  only,  seat  of  the  disease  :  and  here 
it  strikes  me  a  fallacy  exists,  leading  to  erroneous  principles  of  practice. 
In  May,  1834,  while  I  was  in  medical  charge  of  the  68th  regiment, 
(a  fine  corps,  composed  of  men  in  robust  health,)  then  recently  arrived 
at  Madras,  the  funeral  of  a  general  officer  took  place ;  to  which,  unfor- 
tunately, the  men  were  marched  out  at  an  early  hour  in  the  afternoon, 
buttoned  up  in  red  coats  and  military  stocks, — at  a  season,  too,  when 
the  hot  land  winds  had  just  set  in,  rendering  the  atmosphere  dry  and 
suffocating  even  under  shelter  of  a  roof,  and  when  the  sun's  rays  were 
excessively  powerful.  The  consequence  was,  that  after  proceeding  two 
or  three  miles,  several  men  fell  down  senseless.  As  many  as  eight  or 
nine  were  brought  into  hospital  that  evening,  and  many  more  on  the 


182  CLINICAL   MEDICINE. 

following  day ;  three  died— one  on  the  spot,  and  two  within  a  few  hours. 
The  symptoms  observed  (and  they  were  ahke  in  these  three  cases)  were, 
first,  excessive  thirst,  and  a  sense  of  faintness  ;  then  difficulty  of  breath- 
ing, stertor,  coma,  lividity  of  the  face,  and  in  one,  whom  I  examined, 
contraction  of  the  pupil.  The  remainder  of  the  cases,  in  which  the 
attack  was  slighter,  and  the  powers  of  re-action  perhaps  greater,  or  at 
all  events  sufficiently  great,  rallied ;  and  the  attack  in  them  ran  on  in- 
to either  an  ephemeral  or  more  continued  form  of  fever.  The  symptoms 
of  these  three  cases  did  not  more  closely  resemble  each  other  than  did 
the  post  mortem  appearances.  The  brain  was,  in  all,  healthy ;  no  con- 
gestion or  accumulation  of  blood  was  observable ;  a  very  small  quantity 
of  serum  was  effused  under  the  base  of  one,  hut  in  all  three  the  lungs 
were  congested  even  to  blackness  through  their  entire  extent ;  and  so 
densely  loaded  were  they,  that  complete  obstruction  must  have  taken 
place.  There  was  also  an  accumulation  of  blood  in  the  right  side  of 
the  heart,  and  the  great  vessels  approaching  it/' 

Since  our  last  meeting,  some  cases  of  fever  have  occurred  in  our 
wards,  which  have  presented  too  many  points  of  interest  to  be  passed 
over  without  any  observation.  A  very  curious  case  occurred  here,  in  a 
man  named  Toole,  who  was  admitted  on  the  4th  of  January.  This 
patient  is  a  robust  labouring  man,  about  thirty  years  of  age,  and  had 
been  ill  with  fever  for  ten  or  eleven  days  before  admission.  Of  his  pre- 
vious history  we  could  learn  nothing ;  but  when  he  came  under  our 
care  he  appeared  very  ill,  and  exhibited  great  depression  of  the  vital 
energies,  so  that  we  found  it  necessary  to  encourage  reaction  by  the 
application  of  heat  to  the  surface  of  the  body,  frictions,  warm  fomen- 
tations, and  the  internal  administration  of  wine  and  carbonate  of  am- 
monia. On  the  following  night  reaction  became  established ;  next  day 
he  became  irritable  and  restless,  and  towards  night  was  Seized  with  de- 
lirium. The  nurse  omitted  to  report  his  state  to  our  apothecary  Mr. 
Parr,  or  the  resident  pupil ;  he  was  thus  left  without  any  treatment  un- 
til next  morning.  Now,  this  is  a  matter  of  much  regret  to  me,  and  I 
think  I  cannot  do  a  more  essential  service  to  those  who  are  about  to 
enter  on  the  practice  of  their  profession  than  to  impress,  as  strongly  as 
I  can,  the  indispensable  necessity  of  watching  fever  patients  with  the 
most  anxious  and  unremitting  diligence.  In  a  case  of  bad  fever  a 
single  visit  in  the  day  wiU  never  suffice ;  two,  and  even  three  visits  will 
be  required ;  and  when  the  patient  is  in  a  doubtful  or  dangerous  con- 
dition, it  will  be  often  necessary  to  have  a  properly  educated  medical 
person  in  constant  attendance,  prepared  to  meet  every  emergency,  and 
counteract  or  modify  every  unfavourable  change.  Eever  wiU  often  run 
on  for  several  days  without  any  change  calculated  to  arrest  our  attention. 


HEAD  SYMPTOMS  IN  FEVER.  183 

or  call  for  tlie  adoption  of  any  new  measures,  and  yet,  in  the  space  of 
six  hours,  an  alteration  may  occur,  of  which  the  physician  should  have 
early  and  full  information. 

Well,  this  man  remained  without  any  treatment  for  several  hours 
after  delirium  commenced.  On  the  sixth  we  ordered  his  head  to  be 
shaved  and  leeched,  and  prescribed  tartar  emetic,  in  doses  of  a  quarter 
of  a  grain,  every  second  hour.  Next  day  we  found  him  as  bad  as  ever. 
The  tartar  emetic  had  failed  in  diminishing  the  cerebral  symptoms,  and 
his  delirium  had  rather  increased.  We  found  also  on  inquiry,  that  he 
had  no  sleep  for  the  last  three  nights.  His  pulse  was  weak  and  rapid, 
his  eyes  suffused,  his  restlessness  and  delirium  such  that  he  required  a 
person  to  sit  by  him  constantly,  and  prevent  him  from  getting  out  of 
bed.  Under  these  circumstances,  we  ordered  five  drops  of  black  drop 
to  be  added  to  each  dose  of  the  tartar  emetic  mixture,  of  which  he 
took  an  ounce  every  tliird  hour,  that  is,  about  a  quarter  of  a  grain  of 
tartar  emetic.  He  took  four  doses  of  this  during  the  night ;  and  next 
morning  we  found  that  the  delirium  and  sleeplessness  continued  still 
unabated,  and  that  the  man  was  sinking  fast  into  a  state  of  stupor  and 
insensibility.  He  neither  answered  questions,  nor  put  out  his  tongue 
when  desired ;  he  had  subsultus,  and  was  muttering  to  himself  with 
great  volubihty  and  rapidity  of  utterance.  Indeed,  his  condition  was 
such  that  I  had  no  hope.  Among  other  symptoms,  I  should  mention 
that  he  had  contraction  of  the  pupils,  a  symptom  of  very  unfavourable 
augury  in  fever.  Having  failed  with  tartar  emetic  alone,  and  afterwards 
with  tartar  emetic  in  combination  with  opium,  I  had  now  to  seek  for 
some  other  means  of  subduing  cerebral  irritation,  and  in  this  emer- 
gency had  recourse  to  the  use  of  turpentine — a  remedy  which  I  was 
inclined  to  adopt  in  preference  to  any  other,  as  there  was  some  fulness 
of  the  abdomen,  and  other  symptoms  indicating  the  existence  of  con- 
gestion of  the  intestinal  mucous  membrane.  I  therefore  ordered  two 
drachms  of  the  oil  of  turpentine  to  be  made  up  into  a  draught  with 
a  little  oil  and  mucilage,  and  administered  every  second  hour. 

I  was  guided  here  by  a  knowledge  of  the  fact,  that  turpentine  exer- 
cises a  very  remarkable  influence  over  many  forms  of  nervous  irritation. 
I  can  refer  for  illustration  to  many  affections  of  the  nervous  system 
characterised  by  excitement,  in  which  turpentine  has  been  employed 
with  the  most  signal  benefit.  Thus,  we  frequently  find  it  a  most  valu- 
able agent  in  the  treatment  of  chorea,  of  epilepsy,  and  of  the  convul- 
sive fits  of  children.  We  have  frequently  experienced  benefit  from  its 
use  in  the  treatment  of  spasmodic  affections  of  the  stomach  and  bowels ; 
in  hysteria,  tympanitis,  and  the  subsultus  of  fever,  we  often  derive  from 
it  the  most  rapid  and  effectual  relief.     You  recollect  a  case  of  typhus 


184  CLINICAL   MEDICINE. 

whicli  was  lately  under  treatment  in  our  wards,  and  of  which  one  of 
the  most  prominent  symptoms  was  general  and  continued  subsultus ; 
and  you  have  all  witnessed  how  much  rehef  the  patient  obtained  from 
small  doses  of  oil  of  turpentine.  Hence  I  was  led  to  conclude  that  it 
might  be  employed  with  benefit  in  the  latter  stages  of  fever,  where  vas- 
cular excitement  is  greatly  abated,  and  where  the  most  prominent  symp- 
toms are  irritation  of  the  nervous  centres,  with  more  or  less  congestion 
of  the  gastro-intestinal  mucous  membrane.  In  this  case,  however,  I 
must  confess  I  used  it  as  a  last  resource,  and  did  not  anticipate  the 
very  striking  results  which  followed  so  unexpectedly.  After  the  second 
or  third  dose  the  patient  had  two  or  three  full  motions  from  the  bowels, 
and  shortly  afterwards  fell  into  a  sound  and  tranquil  sleep,  from  which 
he  awoke  rational  and  refreshed.  He  is  now  wonderfully  improved  in 
every  respect,  and  I  have  no  doubt  that  his  convalescence  will  go  on 
favourably. 

There  is  one  symptom  in  this  man^s  case  which  is  worthy  of  your 
attention,  as  connected  with  the  history  of  fever,  although  in  other 
respects  it  does  not  seem  to  possess  much  importance.  I  allude  to  the 
bullae  which  have  appeared  on  the  calves  of  his  legs,  on  the  inside  of 
the  ankles,  and  on  the  soles  of  the  feet.  This  affection  seems  to  be- 
long to  that  class  of  eruptive  diseases  which  are  occasionally  observed 
during  the  course  of  idiopathic  fevers,  particularly  those  which  have 
arisen  from  the  introduction  of  an  animal  poison  into  the  system. 
Thus,  we  sometimes  find  an  eruption  of  pustules,  sometimes  of  vesicles 
(as  the  miliary) ;  occasionally  we  have  bullae,  and  not  unfrequently 
erysipelas. 

We  have  had  another  case  of  spotted  or  eruptive  typhus,  in  a  man 
named  Henry  Harpur,  which  has  exhibited  in  the  strongest  manner  the 
value  of  a  combination  of  tartar  emetic  and  opium  in  diminishing  cere- 
bral irritation,  and  bringing  about  a  favourable  change  in  cases  charac- 
terised by  symptoms  of  alarming  and  imminent  danger.  Those  who 
have  witnessed  Harpur's  case  will  confess  that  few  cases  could  present 
a  more  unpromising  appearance.  He  had  violent  dehrium,  requiring 
the  restraint  of  the  strait  waistcoat,  a  furious  aspect,  suffusion  of  the 
eyes,  constant  raving  and  muttering,  and  perfect  sleeplessness.  His 
pulse  was  weak,  thready,  and  rapid ;  his  tongue  and  lips  parched,  fis- 
sured, and  black ;  his  breathing  quick  and  irregular ;  and  his  cerebral 
symptoms  of  such  intensity  as  to  leave  Httle  or  no  ground  for  hope. 
In  addition,  he  had  continued  and  general  subsultus,  and  constant 
irregular  motions  of  the  extremities.  Now,  this  man  has  been  rescued 
from  a  state  of  the  most  imminent  danger,  and  restored  to  convales- 
cence, by  the  use  of  tartar  emetic  and  opium.     Those  who  saw  the 


HEAD    SYMPTOMS    IN    FEVER.  185 

case  two  days  since,  and  who  have  noticed  the  remarkably  improved 
state  of  the  patient  to-day,  will  agree  with  me  in  saying  that  so  favour- 
able a  result  could  scarcely  be  expected.  In  this  case  the  tartar  emetic 
and  opium  were  combined  with  musk  and  camphor.  "VYhere  great  sub- 
sultus  tendinum  is  present,  in  addition  to  the  usual  symptoms  of  cere- 
bral excitement,  I  am  in  the  habit  of  combining  musk  and  camphor 
with  tartar  emetic,  in  the  following  form : — 

R.     Mucilaginis  Gummi  Arabici,  f.^ss. 
Syrupi  Papaveris  albi,  f.^j. 
Antimonii  Tartarizati,  gr.  ij. 
Camphorse,  gr.  xv. 
Moschi,  d'lj. 
Aquae,  f.^ivss.  Misce. 

The  camphor  should  be  previously  triturated  with  a  few  drops  of 
alcohol,  and  the  whole  must  be  rubbed  up  into  the  form  of  an  emulsion, 
of  which  a  table-spoonful  is  to  be  taken  every  second  hour,  until  co- 
pious discharges  of  fluid  yellow  fecal  matter  take  place — an  occurrence 
always  attended  by  much  rehef  of  the  cerebral  and  nervous  symptoms, 
and  wliich  marks  the  period  at  which  we  ought  to  desist  from  the  fur- 
ther use  of  tartar  emetic.  In  the  case  which  we  are  now  considering, 
the  medicine  was  administered  in  draughts,  each  of  which  contained 
half  a  grain  of  tartar  emetic,  ten  grains  of  musk,  five  grains  of  cam- 
phor, and  about  ten  drops  of  laudanum.  After  taking  three  such 
draughts,  the  patient  fell  into  a  quiet  sleep,  which  continued  for  several 
hours.  He  awoke  quite  rational ;  and  since  that  period  his  improve- 
ment has  been  steady  and  progressive.  I  have  not  time  to  enter  any 
further  into  the  particulars  at  present,  and  merely  allude  to  it  as  one  of 
those  instances  in  which  we  have  succeeded  in  allaying  symptoms  of 
cerebral  excitement,  where  the  state  of  the  patient  afforded  very  little 
grounds  for  any  hope  of  a  favourable  termination. 


186 


LECTURE  XV. 

BED-SORES   IN   FEVER. — CONTAGION. SYMPTOMS   OF   CONGESTION    OR 

INFLAMMATION    OF    THE    BRAIN    IN    FEVER. 

A  WOMAN  has  been  admitted  lately  who  had  been  labouring  under  fever 
for  a  considerable  time  before  she  came  into  the  hospital.  This  poor 
creature  seems  to  have  been  in  very  miserable  circumstances  during  her 
illness ;  her  bedding  must  have  been  totally  neglected,  and  no  attention 
paid  to  cleanliness,  for  on  her  admission,  though  nearly  free  from  fever, 
she  was  covered  with  bed  sores  to  a  frightful  extent.  Almost  every 
point  which  had  been  subjected  to  pressure  had  ulcerated,  and  the 
ulcers  went  on  undermining  the  skin,  and  committing  terrible  devas- 
tation in  the  areolar  substance.  Cases  like  this  require  great  care  and 
unremitting  attention ;  it  is  on  the  exercise  of  an  active  and  untiring 
humanity  that  the  cure  wiU  mainly  depend.  In  the  first  place,  you  are 
to  recollect  that  the  efforts  of  the  constitution  towards  the  re-establish- 
ment of  health  are  impeded  by  the  irritation  of  the  sores ;  sleep  is 
prevented,  and  the  patient  kept  in  a  state  of  continual  suffering,  while 
a  constant  drain  from  the  system  is  kept  up  by  the  ulcerative  discharge, 
adding  to  the  amount  of  existing  debihty.  Hence  a  pseudo-febrile 
state  arises,  characterised  by  quick  pulse,  restlessness,  and  want  of  sleep, 
somewhat  akin  to  that  which  is  produced  by  scrofulous  irritation.  The 
appearance,  however,  of  general  excitement  of  the  system  should  never 
prevent  the  physician  from  adopting  every  mode  of  strengthening  the 
patient  as  much  as  possible.  You  will  not  succeed  in  removing  this 
condition  by  an  antiplilogistic  regimen ;  the  patient  requires  tonics  and 
narcotics,  with  a  nutritious  but  not  stimulating  diet.  If  you  put  him 
on  a  low  regimen,  and  give  anti-febrile  medicines,  you  will  do  mischief, 
you  will  increase  the  existing  debility,  and  add  to  the  source  of  febrile 
excitement.  Your  practice  should  be  to  prescribe  a  nutritious  diet, 
wine,  and  the  sulphate  of  quina,  and  to  treat  the  sores  with  stimulant 


BED-SORES    IN    FEVER.  187 

applications.  The  local  application  which  we  find  most  beneficial  in 
such  cases,  is  one  composed  of  two  ounces  of  castor  oil,  and  one  of 
balsam  of  Peru,  which  is  to  be  applied  on  pledgets  of  lint,  and  covered 
wdth  a  poultice  of  linseed  meal  two  or  three  times  a  day.  In  addition 
to  this,  we  direct  the  sores  to  be  washed  night  and  morning  with  a 
solution  of  chloride  of  soda,  in  the  proportion  of  twenty  or  thirty  drops 
of  the  saturated  solution  to  an  ounce  of  water.  We  also  direct  the 
patient  to  lie  occasionally  on  her  face,  and  enforce  the  strictest  attention 
to  cleanliness  on  the  part  of  the  nurse.  Dr.  Arnotf  s  hydrostatic  bed 
is  an  excellent  adjuvant  in  the  treatment  of  this  disease. 

Such,  then,  is  an  outline  of  our  mode  of  treatment  of  bed  sores  in 
fever.  We  order  the  patient  nourishing,  but  not  heating  food ;  we  give 
wine,  regulating  its  quantity  according  to  its  effects  on  the  system,  and 
the  liking  of  the  patient ;  we  prescribe  small  doses  of  the  sulphate  of 
quina,  and  administer  an  opiate  at  night  to  allay  irritability,  and  procure 
sleep.  The  local  treatment  consists  in  the  use  of  stimulant  and  detergent 
apphcations,  poultices,  attention  to  cleanliness  and  change  of  position. 

Let  me  however  beg  your  attention  for  a  few  moments,  while  I  dwell 
a  little  more  at  length  on  the  subject  of  bed-sores,  a  very  troublesome 
occurrence  common  to  most  cases  of  protracted  illness,  requiring  the 
greatest  attention  and  care  on  the  part  of  the  physician,  and  in  the 
treatment  of  wdiich  much  ignorance  is  too  often  displayed  by  young  as 
well  as  old  practitioners.  If  the  duration  of  your  patient^s  complaint 
renders  him  liable  to  such  affections,  how  are  you  to  act  so  as  to  obviate 
them  ?  In  the  first  place,  you  must  pay  particular  attention  to  the  state 
of  his  bed.  One  of  the  best  modes  I  am  acquainted  with  of  preventing 
the  formation  of  bed-sores  is,  to  keep  your  patient  perfectly  clean,  to 
shift  him  frequently,  and  to  take  particular  care  to  prevent  him  from 
l}ang  in  the  wet.  A  physician  should  never  trust  the  arrangements 
connected  with  his  patient's  manner  of  lying  to  the  discretion  of  nurses ; 
he  should  always  look  to  it  himself.  You  are  advised  to  make  your 
patient  change  his  posture  to  obviate  the  effects  of  pressure,  and  to  use 
cushions  of  various  kinds.  All  these  rules  are  good.  You  are  also 
told  to  wash  the  parts  with  camphorated  spirits  of  wine  when  any  disco- 
loration appears.  This,  too,  is  useful.  But,  in  spite  of  all  this,  after 
fever  has  continued  for  some  time,  and  your  patient  has  become  debili- 
tated, bed-sores  will  come  on  not  only  in  consequence  of  the  effects  of 
pressure,  but  also  from  the  tendency  in  the  constitution  to  form  those 
sores.  You  remember  the  case  of  a  man  who  had  a  bed-sore  under  the 
skin  of  the  sole  of  the  foot,  and  another  under  that  of  the  heel, — parts 
totally  exempt  from  pressure. 

When  the  first  redness,  indicating  the  approach  of  a  bed-sore,  has 


188  CLINICAL  MEDICINE. 

made  its  appearance,  various  otlier  means  are  usually  adopted.  Some 
advise  the  application  of  pledgets  of  lint  moistened  with  camphorated 
spirits,  and  they  endeavour  to  keep  these  pledgets  in  contact  with  the 
part,  by  means  of  bandages  or  adhesive  plaster.  Others  use  dry  lint, 
or  hair-powder,  and  many  are  in  the  habit  of  immediately  covering  the 
affected  portion  of  the  skin  with  adhesive  plaster  alone.  The  latter  ap- 
plication too  often  aggravates  the  mischief,  by  exciting  a  rash  and  itch- 
iness in  the  surrounding  integuments,  which  become  an  additional  source 
of  inconvenience,  and  often  force  the  patient  to  scratch  the  irritated 
parts  in  such  a  manner  as  to  disturb  and  remove  all  the  dressings. 
You  must  recollect,  too,  gentlemen,  that  fever  patients  are  always  rest- 
less, and  frequently  delirious,  and  consequently  they  are  constantly 
changing  their  position,  and  tossing  about  in  the  bed,  so  that  it  is  quite 
impossible  to  make  use  of  any  contrivance  capable  of  keeping  these  ap- 
plications in  their  place.  After  they  have  been  fixed  on  and  adjusted 
with  the  greatest  ease,  if  you  return  in  a  few  hours,  you  will  find  them, 
if  not  removed  altogether  from  the  part,  so  wrinkled  and  crumpled,  as 
to  form,  by  the  inequality  of  their  pressure,  new  sources  of  irritation. 
"What,  then,  is  to  be  done  ?  What  means  do  I  recommend  to  enable 
us  to  avoid  so  serious  an  evil  ?  A  case  of  this  kind  cannot  be  too  vigi- 
lantly watched,  and  it  is  only  by  the  most  anxious  attention  and  care 
bestowed  upon  every  thing  connected  with  the  cleanliness,  dryness,  and 
comfort  of  your  patient,  that  you  can  avert  the  formation  of  bed-sores 
in  protracted  and  putrescent  fever. 

In  private  practice,  I  never  treat  a  fever  of  this  nature  without 
having  a  second  bed  in  the  patient's  apartment.  After  the  eleventh 
or  twelfth  day,  the  patient  is  removed  from  one  bed  to  another  every 
twenty-four  hours ;  and  when  the  disease  is  still  further  advanced,  par- 
ticularly if  the  patient  wets  the  bed,  the  removal  may  take  place  every 
twelve  hours.  The  moment  he  is  changed,  all  the  foul  sheets  and 
blankets  are  removed  from  the  apartment,  and  if  necessary  a  fresh  mat- 
trass  is  provided.  Many  will  contend,  that  the  same  object  will  be 
gained  by  carefully  shifting  the  patient  from  one  part  of  the  bed  to 
another,  and  by  a  diligent  attention  to  dryness,  by  means  of  a  constant 
renewal  of  sheets  and  clothes  placed  under  him.  These  expedients 
must  be  used  in  both  cases,  but,  without  the  change  of  bed  all  our 
efforts  will  be  too  frequently  ineffectual.  During  the  progress  of  long- 
continued  fevers,  the  relatives  and  nurses  of  the  sick  are  apt  to  become 
jaded  and  worn  out  at  the  very  time  when  the  greatest  vigilance  and 
activity  are  necessary ;  it  is  then  that  the  physician  ought  to  redouble 
his  vigilance — he  ought  not  to  trust  too  implicitly  to  what  is  told*  him, 
but  inquire  into  and  examine  everything  himself. 


BED-SORES    IN    FEVER.  189 

It  is  scarcely  necessary  to  observe,  that  the  fresh  bed  must  be  well 
heated  with  a  warming-pan,  and  that  when  the  patient  is  weak,  liis 
removal  must  be  effected  with  the  greatest  care,  and  he  must  be  carried, 
as  nearly  as  possible  in  an  horizontal  position,  from  one  bed  to  the 
other.  When  these  precautions  are  observed,  it  is  wonderful  what  ad- 
vantage is  derived  from  this  plan.  Indeed  nothing  can  be  more  grateful 
than  this  removal  from  a  tossed,  foul,  and  wet  bed,  to  one  that  is 
smooth,  clean,  and  in  every  respect  comfortable.  How  often  have  I 
seen  this  change  immediately  followed  by  a  sound  and  refreshing  sleep. 
To  be  successful  practitioners,  gentlemen,  you  must  not  be  merely 
scientific  physicians,  but  you  must  understand  the  most  minute  duties 
of  the  nurse. 

If,  notwithstanding  these  precautions,  bed-sores  should  arise,  or  if 
you  are  called  to  a  case  where  they  have  already  commenced,  there  is 
considerable  redness  and  heat  of  skin  in  the  affected  part ;  it  looks 
angry,  and  is  slightly  elevated  and  buffy  in  the  centre ;  nay,  there  may 
be  even  slight  abrasion  of  the  skin,  leaving  an  unhealthy  festering 
surface.  What  is  to  be  done  ?  Wash  the  parts  well,  three  or  four 
times  a  day,  with  a  strong  solution  of  nitrate  of  silver — ten  or  fifteen 
grains  to  the  ounce  of  water ;  keep  the  part  perfectly  dry  in  the  inter- 
vals between  its  application,  and  it  is  wonderful  what  a  speedy  amend- 
ment will  take  place.  This  plan  of  treatment  I  first  saw  successfully 
employed  at  the  suggestion  of  Mr.  Kirby,  in  a  case  of  fever,  where  I 
thought  it  perfectly  impossible  to  prevent  the  formation  of  extensive, 
and  probably  fatal,  sloughing.  You  cannot  conceive  how  rapidly  the 
swelling,  heat,  redness,  and  puffiness  of  the  part  subsided  under  the 
use  of  this  remedy;  to  me  it  was  perfectly  novel;  but  when  we  reflect 
upon  its  utility  in  erysipelas,  we  are  only  surprised  that  it  was  not  be- 
fore suggested  in  the  treatment  of  iiicipient  bed-sores. 

With  respect  to  the  present  epidemic  fever,^  we  have  now  seen  so 
many  instances  of  its  direct  communication  from  one  point  to  another, 
in  our  wards,  that  we  are  induced  to  believe  it  to  be  contagious.  Erom 
the  great  number  of  applicants  labouring  under  serious  and  threatening 
diseases,  we  are  sometimes  obliged  to  put  into  our  fever  wards,  patients 
afi'ected  with  local  inflammations,  accompanied  by  symptomatic  inflam- 
matory fever ;  several  of  these,  while  recovering,  have  been  attacked 
with  symptoms  of  the  present  epidemic.  A  man  was  admitted  last  week 
into  the  fever  ward  with  violent  pneumonia ;  the  right  lung  was  exten- 
sively hepatised,  and,  in  addition  to  this,  the  pleura  was  found  to  be 
engorged  over  a  large  portion  of  its  surface.     The  case  was  one  of  ex- 

*  This  observation  applies  to  the  epidemic  of  1834. 


190  CLINICAL   MEDICINE. 

treme  distress,  and  the  state  of  the  patient  apparently  hopeless ;  how- 
ever, by  appropriate  depletion,  assisted  by  mercury  and  blisters,  con- 
valescence became  established,  and  the  pulmonary  symptoms  were 
rapidly  subsiding.  His  system  was  still  under  the  influence  of  mercury, 
his  fever  had  disappeared,  his  dyspnoea  was  relieved,  his  cough  and  all 
the  other  symptoms  nearly  gone,  when  he  was  suddenly  attacked  with 
fever,  and  that  of  the  same  character  as  prevailed  among  the  patients 
in  the  same  ward.  This  is,  I  believe,  the  sixth  or  seventh  case  in  which 
patients  labouring  under  some  other  form  of  disease,  have  been  seized 
with  symptoms  of  the  present  epidemic,  while  lying  in  the  same  ward 
with  fever  patients.  I  have  thought  it  necessary  to  make  this  observa- 
tion, because  you  will  find  it  asserted  in  medical  works,  and  by  physi- 
cians of  considerable  eminence,  that  in  hospitals  fever  does  not  spread 
from  one  patient  to  another,  and  that  where  it  does  appear  among 
many  individuals  in  the  same  house,  its  spread  is  chiefly  favoured  by 
want  of  cleanliness  and  proper  ventilation.  This,  however,  we  can 
state  to  be  the  fact,  that  fever  will  spread  among  patients  in  the  same 
ward,  independent  of  anything  connected  with  filth  or  foul  air,  for  we 
have  seen  it  occur  in  our  wards,  which  I  can  assert  are  kept  as  clean, 
and  as  well  ventilated,  as  any  in  the  kingdom. 

There  is  one  circumstance  connected  with  this  case  worthy  of  remark, 
with  reference  to  the  supposed  anti-febrile  properties  of  mercury.  It 
has  been  stated,  that  mercury  exercises  a  prophylactic  influence  over 
the  system,  and  several  persons  who  have  cultivated  medicine  with  suc- 
cess, but  particularly  some  army  surgeons,  of  high  authority,  have  as- 
serted that  the  use  of  mercury  not  only  cures  fever,  but  also  secures 
against  it.  I  am  afraid  that  in  this  and  other  cases,  mercury  has  more 
credit  than  it  deserves.  I  have  seen  persons  under  the  influence  of 
mercury  take  cholera  and  die  of  it ;  and  here  we  find  a  man,  whose 
mouth  is  still  sore,  in  whom  salivation  had  not  ceased,  getting  an  attack 
of  fever  at  a  time  when  he  had  just  recovered  from  another  disease. 
This  shows  that  mercury  is  not  to  be  looked  upon  as  a  prophylactic  in 
cases  of  fever  of  a  contagious  nature.  We  cannot  always  cure  or  pre- 
vent fever  with  mercury ;  on  the  contrary,  where  fever  of  a  particular 
kind  is  present,  it  prevents  the  constitution  from  yielding  to  its  influ- 
ence. Thus,  in  a  case  of  hectic  fever,  brought  on  by  suppuration  of 
the  liver,  it  has  been  found  impossible  to  bring  the  system  under  the 
influence  of  mercury. 

There  is  a  case  in  the  female  fever  ward  wliich  requires  a  passing  ob- 
servation. A  young  woman,  previously  in  the  enjoyment  of  good 
health,  was  seized  with  symptoms  of  fever  after  exposure  to  cold ;  she 
got  rigors,  followed  by  headache,  hot  skin,  thirst,  nausea,  and  accele- 


RIGORS    IN    THE    COURSE    OF    FEVER.  191 

ration  of  pulse.  It  is  unnecessary  for  me  to  detail  the  symptoms  which 
attended  her  illness  during  the  past  week ;  1  shall  content  myself  with 
pointing  out  the  symptoms  which  particularly  attracted  my  attention  to 
her  case  on  Saturday  morning.  At  that  time  her  fever  had  increased  ; 
she  complained  of  severe  headache  and  restlessness  ;  had  foul  tongue, 
thirst,  and  symptoms  of  gastro-intestinal  irritation.  Such  matters, 
demand  no  very  particular  consideration ;  what  chiefly  fixed  my  atten- 
tion was  the  occurrence  of  slight  and  transient  rigors  during  my 
examination  :  I  observed  her  shuddering  three  or  four  times  in  the 
space  of  a  few  minutes.  On  questioning  her  respecting  these  brief 
rigors,  she  informed  me  that  they  had  occurred  with  more  or  less 
frequency  for  the  last  three  days.  Now,  whenever  you  meet  with  a 
symptom  of  this  description  in  fever,  be  on  your  guard ;  watch  the  case 
with  anxious,  unremitting  attention,  and  never  omit  making  a  careful 
examination.  It  is  in  this  way  that  one  of  the  worst  complications  of 
fever — treacherous  and  fatal  disease  of  the  brain — very  often  commences. 
On  examining  this  girl,  we  found  that  she  had  not  only  headache,  but 
also  acute  pain  referred  to  the  left  ear,  the  external  meatus  of  which 
was  observed  to  be  hot  and  tender  to  the  touch.  In  addition  to  this, 
we  were  informed  by  the  nurse  that  she  had  been  seized  with  a  sudden 
fit  of  vomiting  shortly  after  we  left  the  ward  on  the  day  before.  Here 
was  an  array  of  threatening  symptoms  calculated  to  awaken  attention  in 
any,  even  the  most  heedless  observer.  A  patient,  after  exposure  to 
cold,  is  attacked  with  symptoms  of  fever ;  she  has  headache  and  rest- 
lessness ;  she  then  begins  to  complain  of  acute  pain  in  the  ear,  darting 
inwardly  towards  the  brain  ;  and,  finally,  is  seized  with  sudden  vomiting. 
Under  these  circumstances,  it  is  not  difficult  to  form  a  diagnosis,  and 
there  can  be  little  doubt  but  that  the  phenomena  here  presented  were 
indicative  of  incipient  inflammation  of  the  membranes  of  the  brain.  It 
is  not  easy  to  say  whether  in  such  cases  the  inflammatory  affection  of 
the  membranes  precedes  the  external  otitis,  or  whether  the  inflammation 
commences  in  the  external  ear  and  spread  inwards,  though  I  am  inclined 
to  adopt  the  latter  supposition,  and  the  circumstance  of  the  fever  and 
earache  arising  from  cold  seems  to  give  an  additional  degree  of  proba- 
bility to  this  view  of  the  question.  Be  this  as  it  may,  there  could  be 
no  doubt  but  that  this  girl  was,  on  Saturday,  labouring  under  incipient 
inflammation  of  the  membranes  of  the  brain,  as  denoted  by  headache, 
rigors,  acute  pain  in  the  ear,  and  vomiting. 

Here  let  me  observe,  gentlemen,  that  in  cases  of  this  description,  I 
look  on  the  occurrence  of  external  tenderness,  not  merely  as  an  indication 
of  an  internal  disease,  but  also  as  a  favourable  symptom.  I  have 
remarked  that  in  all  cases  where  this  happens,  the  physician  becomes 


192  CLINICAL   MEDICINE. 

more  speedily  and  sensibly  aware  of  the  existence  of  internal  disease, 
and  the  remedial  means  employed  act  with  a  more  decidedly  beneficial 
effect.  I  would  prefer  having  to  deal  with  an  inflammatory  affection  of 
the  brain  or  bowels,  accompanied  by  external  tenderness,  and  would 
feel  much  more  certain  as  to  the  result,  than  if  this  symptom  were  but 
faintly  marked,  or  totally  absent.  This  observation  is  founded  on 
experience. 

In  treating  this  case,  you  have  seen  that  I  have  ordered  relays  of 
leeches  to  be  applied  in  the  vicinity  of  the  affected  ear  until  the  earache 
has  ceased.  I  have  long  followed  this  practice  of  applying  a  number 
of  leeches  in  succession  for  the  rehef  of  local  inflammation,  and  I  can 
state  with  confidence  that  the  result  has  been,  in  the  majority  of  cases, 
higlily  satisfactory.  Some  prefer  the  appHcation  of  a  great  many  leeches 
at  once ;  but  my  experience  speaks  strongly  in  favour  of  the  practice  of 
applying  a  small  number,  repeated  at  short  intervals,  until  the  violence 
of  the  local  inflammation  is  subdued.  Relays  of  six  or  eight  leeches 
will  suffice  in  the  majority  of  cases  of  pectoral,  cerebral  or  abdominal 
inflammation.  In  some,  however,  when  the  attack  is  violent,  flfteeii 
or  twenty  must  be  applied  at  once ;  each  succeeding  relay  may  consist 
of  a  smaller  number  than  that  which  preceded  it.  In  this  manner  I 
have  maintained  a  constant  oozing  of  blood  from  the  integuments  over 
an  inflamed  organ  for  twenty-four,  or  even  thirty-six  hours.  In  addition 
to  this,  I  determined  to  bring  her  system  rapidly  under  the  influence  of 
mercury,  and,  with  this  intent,  administered  calomel  to  the  amount  of 
a  scruple  in  the  twenty-four  hours.  These  means  have  acted  favourably, 
and  she  feels  much  better  to-day. 

Allow  me  to  make  one  observation  more  which  this  case  suggests. 
This  young  woman,  you  recollect,  had,  on  her  admission,  some  epigas- 
tric tenderness,  which  we  removed  by  leeching,  and  she  remained  free 
from  any  symptoms  of  gastric  irritation  until  last  Saturday,  when  she 
got  a  sudden  attack  of  vomiting.  Now,  in  all  feverish  complaints^  where, 
during  the  course  of  the  disease,  the  stomach  hecor/ies  irritable  vnthout 
any  ohvions  cause,  and  where  vomiting  occurs  without  any  epigastric  ten- 
derness, you  may  expect  congestion,  or  incipient  inflammation  of  the 
brain  or  its  membranes.  If  called  to  a  case  of  scarlatina,  where  there 
is  severe  vomiting,  and  perhaps  diarrhoea,  unaccompanied  by  thirst  or 
epigastric  tenderness,  what  should  your  practice  be  ?  Are  you  to  direct 
your  attention  to  the  alimentary  canal,  and  endeavour  to  arrest  these 
symptoms  ?  No.  The  vomiting  here  depends  on  active  congestion  of 
the  head,  and  such  cases  are  very  apt  to  end  in  coma,  convulsions,  or 
death,  from  disease  of  the  brain.  You  are  all  aware,  that  in  cases  of 
injuries  of  the  head,  followed  by  congestion  of  the  brain,  vomiting  is 


TUMORS  IN  THE  NECK  TOWARDS  THE  TERMINATION  OF  FEVER.   193 

one  of  the  most  prominent  symptoms.  The  same  thing  occurs  in  fe- 
brile affections^  attended  with  determination  to  the  head.  You  are  not 
to  conclude  that  a  fever  is  gastric^  because  it  commences  with  nausea 
and  vomiting ;  this  is  a  serious,  and  very  often  a  fatal  mistake ;  yet  I 
am  sorry  to  say  it  has  been  committed  by  many  practitioners,  and  I  have 
been  guilty  of  it  myself.  In  such  cases,  you  should  not  waste  time  in 
attempting  to  relieve  gastric  irritation  by  cold  drinks,  and  leeches  to  the 
epigastrium,  or  to  check  diarrhoea  by  clialk  mixture  and  opiates ;  you 
should  direct  your  attention  at  once  to  the  seat  and  origin  of  the  mis- 
chief, and  employ  prompt  and  effectual  means  to  relieve  the  cerebral 
congestion.  Where  the  disease  sets  in  with  severe  vomiting,  unaccom- 
panied by  distinct  evidences  of  gastric  inflammation,  whether  it  be  com- 
mon fever,  or  scarlatina,  or  measles,  or  small-pox,  I  commence  the 
treatment  by  applying  leeches  to  the  head,  convinced  that  in  this  way  I 
shall  be  most  likely  to  prevent  an  approaching  dangerous  congestion  of 
the  brain.  I  am  anxious  to  impress  this  observation  on  your  minds, 
because  I  am  fully  sensible  of  its  importance,  and  feel  certain  that  you 
will  derive  much  advantage  from  bearing  it  in  recollection  during  the 
course  of  your  future  practice. 

There  is  another  subject  which  I  wish  to  bring  before  you  to-day, 
namely,  the  seat  of  the  swellings  which,  in  the  latter  stages  of  fever,  are 
usually  attributed  to  inflanmiation  of  the  parotid  and  sub-maxillary 
glands.  Every  writer  on  the  subject  of  fever  has  noticed  the  occur- 
rence, in  the  last  stage  of  that  disease,  of  tumors  which  not  unfrequently 
suppurate,  and  which  all  have  considered  as  the  consequence  of  inflam- 
mation in  the  glandular  system ;  the  parotid  and  sub-maxillary  glands 
being  the  parts  most  frequently  engaged.  Tour  such  cases  have  lately 
presented  themselves  to  our  observation — two  with  a  favourable,  two 
with  a  fatal  result.  The  latter  afforded  us  an  opportunity  of  examining 
the  nature  and  seat  of  tliis  affection,  with  the  view  of  determining  the 
correctness  of  the  opinion  generally  entertained  concerning  these 
points. 

According  to  the  best  authors,  the  parotid  and  submaxillary  glands, 
towards  the  termination  of  fever,  are  liable  to  become  painful,  tender, 
and  very  considerably  enlarged ;  and  the  tumor  so  formed  is  either  a 
fatal  symptom,  or  else,  becoming  the  seat  of  a  benign  suppuration,  proves 
salutary,  or  even  critical.  When  of  the  former  unfavourable  character, 
they  are  said  sometimes  to  attain  to  a  considerable  size  in  a  very  short 
space  of  time,  and  also  to  be  hable  to  a  disappearance  equally  rapid. 

In  our  first  case,  the  sudden  appearance  of  the  tumor  was  very  re- 
markable, for,  in  the  course  of  a  few  hours,  two  swelhngs  had  been 
formed,  in  their  situation  and  general  appearance  resembhng  mumps  of 
VOL.  I  13 


11)4  CLINICAL    MEDICINK. 

tlie  largest  size.  They  were  so  extremely  tender  tliat  the  patient 
screamed  on  their  being  touched  even  in  the  gentlest  manner^  yet  they 
were  unattended  with  any  cutaneous  redness.  Without  producing  any 
alleviation  of  the  cerebral  affection  that  constituted  tlie  predominant 
symptom  of  this  poor  man's  fever,  these  swellings  somewhat  subsided 
before  his  death,  which  happened  on  the  following  day.  Much  curiosity 
was  excited  among  the  pupils,  with  regard  to  the  nature  of  this  local 
affection,  and  by  many  it  was  considered  as  arising  from  a  sudden  inflam- 
mation and  tumefaction  of  both  parotids;  so  exactly  did  the  tumors, 
in  extent  and  situation,  resemble  the  mumps.  Their  hardness,  it  is 
true,  was  not  so  great  as  that  usually  observed  in  the  latter  disease,  but 
this  circumstance  alone  could  not  be  relied  on  as  a  distinction.  On  ex- 
amination, the  parotids  were  found  raised  up  by  the  tumors,  but  were 
not  enlarged  or  otherwise  altered  in  structure,  except  that  their  inter- 
stitial areolar  tissue  was,  as  it  were,  bathed  in  a  reddish  serous  fluid, 
evidently  the  result  of  a  violent  inflammation  of  a  peculiar  character  and 
short  duration.  The  swellings  were  owing  to  the  effusion  of  a  similar 
fluid,  which  abounded  most  in  the  subcutaneous  areolar  membrane, 
while,  in  that  wliich  pervades  the  substance  of  the  muscles,  not  only  in 
the  superficial,  but  in  that  more  deeply  seated,  it  was  observed  in  lesser 
quantity.  The  intermuscular  spaces  were  also  occupied  by  this  fluid  in 
considerable  abundance. 

It  may,  perhaps,  be  said  that  these  swellings  were  essentially  different 
in  their  nature  from  the  suppurating  tumors  observed  in  fever ;  but 
their  identity  is  proved  by  the  case  of  a  young  man  named  Connor,  in 
whom  swellings,  in  all  respects  precisely  similar,  arose  six  days  pre- 
viously to  his  death.  The  longer  duration  of  the  inflammatory  process, 
of  course,  produced  an  alteration  of  structure  somewhat  different,  but 
still  evidently  only  an  advanced  stage  of  that  just  described,  while  it  was 
also  as  evidently  of  the  class  of  suppurating  tumors.  It  is  worthy  of 
remark,  that  in  Connor's  case,  the  tumor  on  the  right  side,  on  the  fourth 
day  of  its  appearance,  occupied  exactly  the  same  situation  that  is  ob- 
served in  the  mumps,  and  had  likewise  the  same  degree  of  hardness ; 
while  that  on  the  left  side,  which  was  only  of  two  days  standing  at  that 
period,  was  situated  lower  down,  and  was  much  less  firm.  These  swell- 
ings subsided  a  good  deal  a  few  hours  before  his  death.  The  areolar 
tissue,  in  the  parts  before  enumerated,  was  not  infiltrated  merely  with 
bloody  serum,  as  in  the  other  tumors,  but  this  serum  was  everywhere 
mixed  with  pus,  and  the  areolar  tissue  itseK  had  become  dense  and 
friable,  and  was  of  a  reddish,  or  rather  a  flesh  colour.  The  parotid  and 
submaxillary  glands  shared  in  this  affection  of  the  areolar  tissue,  and 
consequently   contributed   their   proportion  to   the   formation    of  the 


TUMORS  IN  THE  NECK  TOWARDS  THE  TERMINATION  OF  FEVER.       195 

tumors ;  but  tliey  by  no  means  constituted  the  whole  of  the  swelHngs, 
or  indeed  any  thing  like  the  greater  portion  of  them. 

A  few  days  after  Connor  had  been  attacked,  a  similar  swelling  arose 
in  a  boy,  named  Byrne,  who  lay  in  the  bed  next  to  Connor ;  but  it  was 
confined  to  one  side,  and  it  occupied  a  position  corresponding  to  the 
parotid,  where  it  was  most  swollen  :  but  in  its  less  tumified  parts  it  ex- 
tended both  further  downwards  and  backwards.  This  tumor  suppu- 
rated, and  formed  an  abscess,  which  was  apparently  much  more  super- 
ficial than  the  great  mass  of  the  swelling,  and  unconnected  with  it ;  for 
when  it  was  opened,  and  its  contents  were  discharged,  the  hardness  and 
swelling  in  the  region  of  the  parotid  seemed  undiminished.  The  abscess, 
however,  continuing  to  discharge  matter,  this  sweUing  gradually  de- 
clined, and  finally  disappeared. 

At  this  very  time  a  woman  in  the  fever  wards  was  attacked  with  a 
similar  swelling,  but  which  was  evidently  neither  in  the  situation  of  the 
parotid  or  submaxillary  gland  :  it  was  confined  to  the  subcutaneous  tis- 
sue immediately  below  the  ear,  and  was  prevented  from  suppurating  by 
the  application  of  leeches. 

The  facts  just  stated  are,  I  think,  gentlemen,  conclusive,  in  proving 
that  the  tumors  hitherto  supposed  to  arise  from  inflammation  of  the 
parotid  or  submaxillary  gland,  and  which  in  fever  sometimes  forebode 
death,  and  are  sometimes  the  precursors  of  returning  health,  are  not 
owing  to  an  affection  confined  in  its  action  to  these  glands ;  but,  on  the 
contrary,  the  inflammation  and  its  consequent  tumefaction  are  seated  in 
the  areolar  membrane  of  all  the  neighbouring  parts :  so  that  the  bulk 
of  the  tumor  is  sometimes  altogether,  and  generally,  for  the  greatest 
part,  made  up  independently  of  disease  of  these  glands.  It  would  be 
rash  to  extend  this  conclusion  to  the  mumps — cynanche  parotidea,  but 
I  may  be  permitted  to  remark  that  I  am  far  from  being  satisfied  that 
the  seat  of  the  tumors  so  called  has  not  been  assumed  without  suf- 
ficient grounds.  Indeed  this  disease  so  rarely,  if  ever,  proves  fatal 
while  the  swellings  persist,  that  I  do  not  know  of  any  post-mortem  exa- 
mination of  the  tumors  of  mumps  on  record.  Our  only  guide,  there- 
fore, is  analogy  ;  and  when  we  recollect  that  our  swellings  agree  with 
mumps,  not  only  in  general  appearance  and  situation,  but  also  in  the 
sudden  manner  in  which  they  arise,  and,  according  to  the  testimony  of 
authors,  in  the  sudden  manner  in  which  they  occasionally  disappear ; 
when  we  recollect,  also,  that,  like  mumps,  they  show  a  decided  ten- 
dency to  be  epidemic ;  we  cannot  avoid  conceding  that  the  points  of 
resemblance  are  strong ;  the  more  so,  that  in  botli  diseases,  the  sudden 
disappearance  of  the  tumor  is  always  dangerous.  The  sympathetic  in- 
flammation of  the  mammae  in  females,  and  of  the  testes  in  males,  which 


196  CLINICAL    MEDICINE. 

not  very  unfrequentlj  follows  retrocession  of  the  tumors  in  cynanclie 
parotidea,  may  be  objected  to  this  analogy,  and  may  be  considered  as 
proving  the  glandular  nature  of  the  swelling  in  mumps.  On  the  other 
hand,  we  know  of  no  other  glands  which  are  liable  to  become,  in  con- 
sequence of  inflammation,  so  enormously  enlarged  in  the  course  of  a  few 
hours,  as  the  parotids  in  mumps,  (if  that  disease  really  depends  on  an 
affection  of  these  glands  alone) ;  and,  indeed,  it  may  be  observed,  that 
acute  inflammation  seems,  in  all  other  glands,  incapable  of  causing  a 
degree  of  swelling  at  all  comparable  to  that  observed  in  mumps.  The 
swelling,  too,  in  other  glands  is  better  defined  and  more  circumscribed, 
and  scarcely  liable  to  the  sudden  retrocessions  observed  so  frequently  in 
cynanche  parotidea.  It  is  a  singular  fact,  that  the  salivary  secretion  is 
not  notably  altered  in  mumps,  and  yet  were  this  disease  dependant 
on  inflammation  of  the  parotids,  a  suppression,  or  at  least  some  altera- 
tion, in  the  quantity  or  quality  of  that  secretion  might  be  expected. 
Such,  gentlemen,  are  the  ideas  which  have  at  the  moment  occurred  to 
me  concerning  the  pathology  of  these  affections — ^ideas  which  I  have 
ventured  to  bring  forward  merely  with  a  view  of  exciting  further  inquiry 
on  the  subject. 


197 


LECTUEE  XVI. 

TARTAR   EMETIC    AND    OPIUM    IN    FEVER   ATTENDED    WITH    CEREBRAL 

EXCITEMENT. 

I  have  several  times  alluded  to  the  use  of  tartar  emetic  in  the  treatraeut 
of  the  cerebral  excitement  and  determination  to  the  head,  which  are  so 
frequently  witnessed  in  the  advanced  stage  of  typhus  fever ;  I  shall  now 
proceed  to  mention  in  detail  some  of  the  beneficial  effects  derived  from 
this  plan  of  treatment,  as  illustrated  by  cases  which  have  recently 
occurred  in  my  own  practice,  or  in  that  of  other  members  of  the  pro- 
fession. 

Did  I  bring  forward  this  plan  of  treatment  as  infallible,  or  if  I  boasted 
that  it  never  failed,  then  indeed  you  might  well  doubt  my  judgment  in 
recommending  it  to  your  notice,  for  infallible  remedies  never  earn  the 
sanction  of  experience ;  but  such  is  not  the  fact.  This  treatment  we  our- 
selves have  seen  will  not  always  succeed ;  nay,  we  must  acknowledge 
that  it  has  occasionally  disappointed  us,  even  where  we  seemed  justified 
in  calculating  upon  success.  But,  gentlemen,  we  must  recollect  that 
every  useful  remedy  is  subject  to  the  same  charge,  and  that  in  the  long 
list  of  therapeutic  agents,  there  does  not  exist  a  single  medicine  which 
is  fairly  entitled  to  the  appellation  of  a  true  and  infallible  specific. 

We  have  failed  in  several  cases  with  tartar  emetic,  either  alone  or 
combined  with  opium  and  other  medicines,  and  patients  labouring  under 
typhus  have  fallen  victims  to  cerebral  disease,  although  we  applied  the 
remedy  with  all  due  diligence.  Yet  I  think  it  but  fair  to  observe,  that 
most  of  the  instances  in  which  we  failed  were  cases  that  had  come 
under  our  notice  at  an  advanced  stage  of  fever,  and  where  the  cerebral 
symptoms  had  been  wholly  overlooked  or  improperly  treated  in  the 
commencement  of  the  disease.  I  may  observe  also,  that  cases  of  this 
description,  in  which  the  cerebral  symptoms  have  been  permitted,  before 
admission  into  hospital,  to  form  themselves  fully,  are  exceedingly  difficult 
to  manage,  and  terminate  fatally  at  a  much  earlier  period  than  the 
ordinary  cases  of  typhus  observed  in  private  practice. 

Maculated  typhus  with  determination  to  the  head,  when  improperly 


198  CLINICAL   MEDICINE. 

treated,  terminates  not  unfrequently  about  tlie  tenth,  eleventli,  or  twelfth 
day;  sometimes  it  is  protracted  to  the  thirteenth  or  fourteenth,  but 
most  usually  it  ends  fatally  about  the  eleventh  or  twelfth.  In  neglected 
cases,  the  cerebral  symptoms  frequently  assume  a  fearful  violence  on  the 
seventh,  eighth,  or  ninth  day,  and  in  such  instances  it  must  be  expected 
that  the  best  and  most  appropriate  plan  of  treatment  will  fail  in  rescuing 
the  patient  from  impending  dissolution.  If,  however,  we  can  find  out 
a  remedy,  which,  in  many  cases,  apparently  desperate,  succeeds  in 
rescuing  the  patient  from  the  jaws  of  death,  we  must  be  satisfied.  A 
case  of  this  description  has  occurred  since  our  last  meeting.  It  has 
excited  the  attention  of  all  who  witnessed  it,  as  well  from  the  violence 
of  the  symptoms,  and  the  apparently  hopeless  state  of  the  patient,  as 
from  the  rapidity  with  which  the  exhibition  of  the  remedies  employed 
was  followed  by  a  striking  and  decided  alteration  in  the  symptoms. 
Any  one  who  saw  him  yesterday,  would  scarcely  recognise  him  as  the 
same  individual  to-day. 

This  man,  named  IFogarty,  was  admitted  about  the  seventh  or  eighth 
day  of  his  fever,  according  to  'the  account  of  his  friends.  Of  course  in 
such  cases  we  cannot  give  impHcit  credence  to  those  loose  statements, 
for  the  lower  class  of  persons  in  this  country  never  calculate  the  time 
during  which  the  patient  remains  out  of  bed  strugghng  against  the 
disease — a  period  which,  in  a  people  inured  to  suffering  and  privation, 
frequently  lasts  three,  four,  or  even  six  days.  "Well,  this  man,  aged 
five-and-twenty,  and  of  rather  robust  constitution,  was  admitted  on  the 
20th  of  December,  being  then  about  eight  or  nine  days  ill.  Previously 
to  admission  he  had  taken  purgative  medicines,  had  his  head  shaved, 
and  six  leeches  appUed  behind  his  ears,  or  to  his  temples,  I  forget  which. 
Now  all  these  measures,  although  perhaps  insufficient,  were  extremely 
proper,  and  must  have  produced  more  or  less  benefit.  When  we 
examined  him  on  the  21st,  we  found  liim  in  a  state  of  high  excitement, 
as  manifested  by  continued  mental  wandering,  incessant  talking  and 
raving,  and  frequent  attempts  to  get  out  of  bed.  He  had  illusions  of 
the  senses  of  sight  and  hearing,  consisting  of  terrific  ocular  spectra, 
and  alarming  sounds,  wliich  threw  him  into  a  state  of  intense  agitation;"^ 
his  eye  was  red  and  watchful,  and  he  never  slept.  Here  then  was  a 
very  threatening  array  of  symptoms — perfect  insomnia,  ocular  spectra, 
illusions  of  the  sense  of  hearing,  a  fiery  eye,  and   incessant   mental 

*  In  my  last  lecture  I  mentioned  that  analogous  symptoms  result  from  increased  or 
diminished  sanguineous  pressure  on  the  brain  ;  the  ocular  spectra  in  Fogarty's  case 
evidently  depended  on  determination  of  blood  to  the  head,  but  in  the  case  of  a  lady,  the 
wife  of  an  eminent  physician,  a  continued  and  varied  succession  of  spectral  illusions 
formed  one  of  the  chief  symptoms,  produced  by  exhausting  hemorrhage  after  delivery. 


TARTAll    EMETIC    IN    FEVER.  199 

wandering.  To  this  was  added,,  great  derangement  of  tlie  wliole  nervous 
system ;  liis  body  was  agitated  from  head  to  foot  by  continual  tremors, 
and  he  had  violent  and  persistent  subsultus ;  his  respiration  was  inter- 
rupted, suspirious,  and  irregular,  amounting  at  one  time  to  forty  in  the 
minute,  afterwards  not  exceeding  twenty-five ;  the  acts  of  inspiration  and 
expiration  were  extremely  unequal,  and  occasionally  accompanied  by 
blowing  and  whistling.  In  a  former  lecture,  I  made  some  observations 
on  this  form  of  respiration,  which  I  termed  cerehral,  from  having  first 
observed  it  in  persons  subject  to  apoplectic  attacks,  either  before  or 
during  the  paroxysms ;  it  is  frequently  observed  in  bad  cases  of  fever, 
and  is  a  symptom  of  the  greatest  importance.  He  also  lay  constantly 
on  liis  back ;  his  pulse  120,  soft,  and  very  w^eak,  so  that  the  canal  of 
the  artery  could  be  obliterated  by  very  slight  pressure ;  his  pupils  were 
somewhat  dilated ;  tongue  parched  and  brown  in  the  centre,  red  at  the 
the  edges  and  tip ;  skin  covered  with  maculae ;  abdomen  soft  and 
full. 

Those  who  have  witnessed  the  case  will  acknowledge  that  the  picture 
I  have  drawn  is  not  too  highly  coloured,  but,  on  the  contrary,  falls  far 
short  of  the  reality,  and  no  doubt  you  all  expected  that  if  we  did  not 
succeed  at  once  in  arresting  the  progress  of  his  symptoms,  the  case 
must  have  proved  rapidly  fatal.  Observe  the  position  in  which  we 
were  placed.  In  the  commencement  of  the  fever,  certain  appropriate 
but  inadequate  remedies  had  been  employed,  and,  under  a  treatment 
proper  but  insufficient,  the  disease  had  progressed ;  it  was  an  example 
of  one  of  the  worst  forms  of  fever,  characterised  by  intense  cerebral 
excitement,  and  accompanied  by  total  want  of  sleep,  persistent  delirium, 
and  excessive  disturbance  of  the  nervous  functions ;  all  these  symptoms 
had  come  on  gradually,  and  arrived  at  their  acme  at  a  period  when  the 
low  and  debilitated  state  of  the  patient  precluded  the  use  of  depletive 
measures  to  such  an  extent  as  to  exert  any  efficient  control  over  the 
most  dangerous  symptoms.  The  apphcation  of  a  few  leeches  would  be 
extremely  hazardous,  and  blistering  w^ould  have  been  wholly  useless  and 
nugatory,  for  before  the  blister  could  rise  the  man  would  be  dead. 

For  these  reasons,  we  concluded  that  the  only  remedy  we  could  have 
recourse  to  with  any  prospect  of  success  was  tartar  emetic.  We  there- 
fore ordered  a  draught  composed  of  two  drachms  of  mint  water,  two 
of  common  water,  and  a  quarter  of  a  grain  of  tartar  emetic,  to  be 
given  every  hour  until  it  produced  some  decided  effect  on  the  constitu- 
tion. You  will  recollect,  here,  that  the  scale  was  vibrating  between 
life  and  death,  that  it  was  necessary  that  our  plan  of  operation  should 
be  at  once  prompt  and  prudent,  decisive  and  cautious.  One  of  the 
pupils  promised  to  stay  by  him  the  whole  day  and  watch  the  effects  of 


200  CLINICAL    MEDICINE. 

the  remedy,  and  I  determined  to  visit  and  examine  him  personally  in 
the  afternoon. 

In  the  course  of  four  hours  he  took  four  doses  of  the  tartar  emetic ; 
the  first  and  second — in  fact  almost  every  dose  vomited  him,  but  not 
immediately.  He  retained  each  dose  for  a  considerable  time,  and  then 
threw  it  up.  After  the  fourth  dose,  it  began  to  act  on  his  bowels,  and 
then  the  medicine  was  suspended  for  some  time,  and  a  small  quantity 
of  porter  administered.  When  I  saw  him  at  eight  o^clock  in  the  even- 
ing, he  had  been  freely  purged,  and  had  discharged  a  considerable 
quantity  of  bihous  yellow  fluid  from  his  bowels.  He  had  also  enjoyed 
about  an  hour's  sleep ;  his  respiration  was  now  more  uniform  and  na- 
tural ;  his  raving  greatly  diminished ;  the  subsultus  and  tremors  were 
nearly  gone,  and  the  man  appeared  quite  tranquil.  I  then  ordered  him 
a  wine  glass  full  of  porter,  "wdth  two  drops  of  black  drop,  to  be  repeated 
every  second  hour  for  three  or  four  turns  successively.  I  saw  that 
the  cerebral  symptoms  were  evidently  diminished,  and  that  there  was  a 
tendency  to  returning  tranquillity  and  repose,  and  I  wished  to  follow  up 
and  assist  the  operations  of  nature.  To-day  this  man  is  in  a  most 
favourable  state.  His  skin  is  covered  with  a  most  profuse  warm  per- 
spiration, he  has  slept  well,  belly  soft  and  natural,  respiration  slow  and 
regular,  and  pulse  diminished  in  frequency ;  he  is  calm,  rational,  and 
composed,  and  I  think  I  am  not  too  sanguine  in  anticipating  for  him  a 
speedy  and  certain  recovery.^ 

It  is  always  an  unpleasing  and  ungracious  task  for  any  individual  to 
be  obliged  to  come  forward  with  proofs  of  the  originality  of  his  contri- 
butions to  science :  this  task  some  have  endeavoured  to  impose  on  me, 
and  have  sought  to  impugn  both  the  originality  and  utility  of  my  me- 
thod of  using  tartar  emetic  and  opium  in  typhus  fever.  Their  argu- 
ments do  not  require  any  answer,  and  may  be  passed  over  in  silence 
without  any  loss  to  you  or  prejudice  to  me,  for  certainly  you  could  de- 
rive little  profit  from  hearing  the  statements  of  my  opponents,  and  I 
but  slight  credit  from  their  refutation ;  suffice  it  then  to  say,  that  the 
prescriptions  filed  by  the  apothecaries  of  Dublin  establish  my  claims, 
for  you  will  search  in  vain  among  them  for  one  bearing  a  date  prior  to 
the  publication  of  my  papers  on  the  use  of  tartar  emetic  and  opium  in 
the  advanced  stages  of  fever j  and  in  which  these  medicines  are  pre- 
scribed in  the  way,  or  anything  like  the  way,  recommended  and  practised 
by  me.  Since  that  date,  such  prescriptions  have  daily  become  more 
numerous,  and  I  am  proud  to  bear  testimony  to  the  general  liberality  of 
the  profession,  for  the  greater  number  of  my  brethren  have  not  merely 

*  He  recovered  rapidly  and  completely. 


TARTAR    EMETIC    AND    OPIUM    IN    FEVER.  201 

tried  my  plan  of  treatment,  but  have  acknowledged  its  utility,  and  have 
hastened  to  assure  me  that  until  my  publications  they  had  not  seen  it 
practised.  Bnt  enough  of  this,  let  us  not  employ  in  general  enco- 
miums that  time  which  may  be  more  profitably  dedicated  to  instructive 
details ;  let  us  therefore  again  recur  to  facts. 

I  have  received  from  Mr.  Burke  and  Dr.  Beauchamp  the  notes  of  an 
extremely  interesting  case  of  this  description.  The  case  is  extremely 
valuable  as  having  been  observed  by  Mr.  Burke  from  the  commence- 
ment ;  I  shall  read  the  whole  of  it  fi'om  his  letter,  as  it  is  well  worthy 
of  attention. 

'^  I  was  called  on  the  25th  of  November  to  see  Mrs.  M.,  a  married 
woman,  without  family,  of  a  weakly  and  nervous  habit,  though  gene- 
rally enjoying  good  health.  She  complained  of  having  had  chilliness 
on  the  preceding  day ;  and  now,  that  she  was  hot,  tliirsty,  had  pain  in 
the  head  and  back,  and  great  debility.  On  examination  I  found  that 
petechiee  covered  the  chest  and  abdomen  ;  the  eyes  suffused ;  face  red ; 
scalp  hot;  pulse  110,  small  and  hard;  tongue  covered  with  a  creamy 
exudation ;  no  abdominal  or  chest  affection ;  secretions  and  excretions 
arrested.  She  was  ordered  some  aperient  medicine,  and  directed  to  be 
kept  very  quiet. 

"  26th. — Passed  rather  an  uneasy  night,  frequent  starlings ;  some 
raving ;  complains  of  headache,  and  that  the  light  and  noise  are  dis- 
tressing ;  pulse  as  before,  face  more  flashed,  bowels  open.  I  directed 
a  cooling  lotion  for  the  head,  and  a  diaphoretic  mixture  containing 
liquor  acetatis  ammonias,  and  nitre.  On  the  27th,  she  complained  of 
the  headache  being  made  worse  by  the  noise  in  the  house,  from  which 
I  determined  to  have  her  removed,  and  I  therefore  did  not  put  any 
active  treatment  into  requisition. 

"30th. — This  day  she  was  removed  to  a  quiet  airy  room.  I 
then  had  her  head  shaved,  eight  leeches  apphed  behind  the  ears, 
and  a  blister  to  the  nape  of  the  neck ;  bowels  opened  by  ene- 
raata. 

"  Up  to  the  5th  of  December,  which  was  the  tenth  day  of  her  illness, 
she  went  on  tolerably  well,  occasionally  raving  at  night ;  tongue  dry 
and  red;  pulse  very  weak,  110;  eyes  much  suffused  ;  face  occasionally 
flushed,  then  pale ;  scalp  hot.  At  this  period  Dr.  Beauchamp  saw  her, 
and  from  the  weakly  habit  of  the  patient,  and  the  peculiar  tremulous 
feel  of  the  pulse,  he  thought  it  advisable  to  let  her  have  some  weak 
chicken  broth  and  hght  negus  ;  the  latter  had  soon  to  be  discontinued 
on  account  of  the  excitement  it  produced. 

"  On  the  14tli  day  she  became  more  delirious  and  somewhat  un- 
manageable, though  previously  very  gentle ;  however,  when  spoken  to 


202  CLINICAL   MEDICINE. 

she  answered  tolerably  reasonably.  Ordered  to  continue  tlie  lotion, 
enemata,  and  saline  draughts. 

"Dr.  Beauchamp  and  I  saw  her  next  day  about  ten  o'clock  in  the 
forenoon,  being  the  fifteenth  day  of  her  fever.  Previous  to  our  going 
into  the  room,  the  nurse  gave  us  a  friglitful  picture  of  the  way  she 
spent  the  night.  She  had  been  perfectly  unmanageable,  continually 
screaming  and  imagining  she  saw  frightful  apparitions,  and  had  been 
convulsed  during  the  night.  On  entering  the  room,  we  found  her  with 
her  hands  outstretched  and  rigid ;  a  mixture  of  wildness  and  terror  in 
her  face,  her  eyes  red  and  protruded,  pupils  contracted,  pulse  not  to  be 
counted,  and  scarcely  to  be  felt ;  feet  cold  and  stiff.  When  spoken  to 
she  made  no  answer,  but  kept  her  eyes  steadily  directed  towards  the 
foot  of  the  bed.  Her  aspect  was  altogether  frightful,  and  Dr.  Beau- 
champ  observed  that  her  state  appeared  to  be  a  combination  of  delirium 
with  hysteria. 

"  The  question  now  was,  what  were  we  to  do  ?  We  dared  not  apply 
leeches,  blisters  would  be  doubtful,  and  the  probability  was  that  the 
patient  would  sink  before  they  vesicated.  There  was  no  indication  for 
cold  to  the  head,  for  the  scalp  was  cool.  Could  we  rely  with  safety  on 
nervous  medicines  ?  their  very  stimulus  might  hasten  her  to  the  tomb. 
The  indication  was  to  relieve  the  brain,  and  the  question  was,  what 
medicine  or  combination  of  medicines  would  effect  this  with  safety  ? 
Under  these  circumstances,  we  happily  thought  of  the  treatment  em- 
ployed by  you  in  somewhat  similar  cases.  We  immediately  ordered  a 
mixture  containing  three  grains  of  tartar  emetic,  half  a  drachm  of 
laudanum,  and  six  ounces  of  water :  of  this  a  tablespoonful  was  admi- 
nistered every  half  hour,  its  effects  being  watched.  We  saw  her  again 
at  one  o'clock  on  the  same  day,  and  had  the  pleasure  of  finding  her 
much  improved.  She  had  taken  three  doses,  and  vomited  twice.  The 
expression  of  her  countenance  was  much  changed,  it  had  lost  its  ferocity 
and  wildness ;  her  tongue  was  now  moist,  perspiration  was  beginning 
to  appear  over  her  body,  the  pulse  was  soft  and  about  100,  and  the 
intelligence,  which  had  been  absent  for  a  considerable  period,  now 
reappeared.  She  was  able  to  answer  our  questions,  and  expressed  her- 
self reheved.  We  ordered  the  medicine  to  be  continued,  giving  a 
tablespoonful  every  hour.  After  taking  two  doses,  she  became  per- 
pectly  quiet,  fell  into  a  profound  and  tranquil  sleep,  perspired  copiously, 
and  at  our  visit  next  morning  at  ten  o'clock,  we  found  her,  to  our 
astonishment,  almost  well.  She  looked  cheerful  and  refreshed,  and 
spoke  of  the  wonderful  relief  she  obtained ;  her  pulse  was  soft,  and 
about  80 ;  her  skin  natural,  and  her  tongue  moist  and  clean.  Dr. 
Beauchamp  did  not  tliink  it  necessary  to  continue  his  visits,  and  all 


TARTAR   EMETIC    AND    OPIUM    IN    FEVER.  203 

that  remained  for  me  was  to  conduct  her  by  proper  regimen  from  con- 
valescence to  perfect  health.     She  is  now  quite  well. 

"  It  is  a  source  of  gratification  to  me  to  have  had  the  able  assistance 
of  Dr.  Beauchamp  on  this  occasion^  and  Ids  presence  during  the  eventful 
period  adds  much  value  to  the  case.  Dr.  Beauchamp  remarked^  at  the 
time  when  hope  had  fled,  that  he  knew  of  no  routine  of  practice  which 
afforded  a  probability  of  being  of  service,  so  that  we  may  fairly  con- 
clude, that  but  for  your  happy  combination  the  patient  must  have 
died." 

This  is  a  very  strong  case ;  indeed  there  could  scarcely  be  a  more 
striking  illustration  .of  the  value  of  tartar  emetic  and  opium  in  the 
treatment  of  the  cerebral  symptoms  of  fever.  The  case  too  was  one  of 
great  danger ;  the  patient  was  of  a  nervous  weakly  habit,  and  during 
the  acme  of  the  disease  she  had  an  attack  of  convulsions.  This  is  a 
very  important  and  most  formidable  symptom  in  fever,  particularly  when 
superadded  to  others  indicating  a  deranged  state  of  the  sensorium. 
AYe  had  a  patient  here,  some  time  back,  who  had  two  convulsive  parox- 
ysms during  the  course  of  his  fever,  and  you  recollect  that  I  told  you 
that  it  was  a  symptom  of  unusual  danger.  Some  time  ago  a  gentleman, 
in  discussing  my  cases,  said  that  convulsions  in  fever  were  not  so  dan- 
gerous, but  I  had  the  satisfaction  of  quoting  for  liim  the  authority  of 
Hippocrates,  to  show  that  persons  who  had  been  attacked  in  tliis  way 
very  seldom  recovered. 

I  shall  next  detail  a  very  remarkable  case,  which  was  communicated 
to  me  by  Mr.  Swift : — 

"J.  Kinsela,  a  labourer,  aged  23,  of  powerful  make,  and  robust 
constitution,  was  attacked  with  fever  about  the  14th  or  15th  of  Ja- 
nuary. He  complained  during  the  ensuing  week  of  intense  headache, 
thirst,  and  debility,  but  had  no  medical  treatment.  On  Saturday,  the 
21st,  he  was  extremely  ill  and  restless,  and  on  Sunday  morning,  wliile 
liis  clergyman  and  several  of  his  friends  were  with  liim,  he  got  out  of 
bed  in  a  state  of  furious  delirium,  seized  a  knife,  and  having  cleared 
the  room,  ruslied  out  into  the  street  in  his  shirt,  where  he  was  secured 
by  a  policeman  and  some  of  his  neighbours,  and  brought  back  to  bed, 
having  previously  wounded  several  of  his  captors  in  the  struggle.  He 
then  fell  into  a  state  of  coma,  and  when  I  saw  him  on  the  following 
Thursday,  the  26th,  he  exhibited  the  following  symptoms : — Decubitus 
on  the  back ;  eyes  nearly  closed  ;  lips  red,  dry,  and  chapped  ;  forearms 
bent  and  agitated  by  apparently  unconscious  movements ;  convulsive 
twitches  of  the  eyebrows  and  angles  of  the  mouth ;  breathing  irregular, 
heavy,  and  somewhat  stertorous,  (of  that  description  which  you  have 
aptly  termed   cerebral)  ;  pulse  oppressed,    unequal,   weak,  and   about 


204  CLINICAL   MEDICINE. 

110;  great  heat  of  seal]!  and  face;  temperature  of  the  body  normal; 
feet  very  cold.  He  had  no  pulmonary  symptoms ;  his  belly  was  soft 
and  apparently  natural,  but  he  gave  indications  of  uneasiness  when 
firm  pressure  was  made  over  the  situation  of  the  stomach  and  small 
intestine.  He  was  raised  up  in  bed,  shaken  roughly,  and  spoken  to 
repeatedly,  but  gave  no  answer ;  nor  would  he  put  out  his  tongue,  or 
open  his  eyes  wlien  requested.  His  tongue,  as  far  as  I  could  see  it, 
appeared  red,  dr}-,  crusted,  and  fissured ;  and  on  raising  his  eyelids,  I 
found  the  eyes  greatly  sufi'used,  and  the  pupils  contracted  nearly  to  the 
size  of  a  pin^s  head. 

"  His  face,  hands,  and  head,  were  bathed  with  warm  vinegar  and 
water,  jars  filled  with  hot  water  applied  to  his  feet,  and  about  two 
o'clock,  P.M.,  he  commenced  taking  tartar  emetic  in  doses  of  a  quarter 
of  a  grain  every  hour.  It  was  combined  with  a  small  quantity  of 
opium. 

"  When  I  saw  liim  again,  about  nine  o'clock  in  the  evening,  he  Avas 
wonderfully  improved.  He  could  be  easily  roused,  answered  qjiestions 
distinctly,  put  out  his  tongue  when  desired,  and  appeared  quite  rational. 
He  had  taken  about  two  grains  of  the  tartar  emetic,  the  effects  of 
which  appeared  to  be  chiefly  confined  to  the  circulating  system.  His 
pulse  was  now  equal  and  regular,  the  temperature  of  liis  body  nearly 
uniform,  and  a  slight  degree  of  moisture  could  be  felt  on  his  skin,  but 
he  was  neither  vomited  nor  purged.  A  mixture,  containing  nitrate  of 
potash  and  tincture  of  hyoscyamus,  was  substituted  for  the  tartar 
emetic ;  the  fomentations  of  warm  water  and  vinegar  w^ere  continued, 
and  he  had  a  purgative  enema  with  turpentine,  which  was  followed  by 
a  full  discharge  from  the  bowels  and  copious  diuresis.  On  Saturday, 
the  28th,  he  had  an  indistinct  but  favourable  crisis ;  liis  tongue  became 
clean  and  soft,  and  his  pulse  diminished  in  frequency.  On  the  following 
Tuesday,  liis  pulse  was  76,  his  tongue  clean,  eyes  clear,  pupils  natural, 
appetite  returning,  so  that  I  considered  it  unnecessary  to  continue  my 
visits  beyond  the  following  day.  His  convalescence  is  now  completely 
established. 

"  I  have  been  particular  in  describing  the  cerebral  symptoms  in  this 
case,  as  the  patient's  head  was  neither  shaved,  bhstered,  nor  leeched. 
A  portion  of  liis  hair  was  cut  off  with  a  scissors,  and  tliis  w^as  all  that 
was  done  in  addition  to  what  I  have  mentioned.  I  attribute  his  reco- 
very to  the  tartar  emetic  and  opium,  as  under  its  use  he  recovered  in  a 
few  hours  from  a  state  of  stupor  and  coma,  which  otherwise  must  have 
speedily  terminated  in  death,  and  I  think  this  valuable  remedy  has 
additional  claims  to  notice,  if  (as  it  would  appear  from  Kinsela's  case) 
it  can  be  employed  as  a  substitute  for  all  the  ordinary  and  expensive 


TARTAR    EMETIC    AND    OPIUM    IN    FEVER.  205 

remedies  used  on  such  occasions, — remedies  which,  in  dispensary  prac- 
tice, and  among  a  pauper  population  Hke  ours,  it  is  often  difficult,  and 
sometimes  impossible  to  procure." 

It  is  well  known  that  delirium  tremens  requires  very  different  modes 
of  treatment,  varying  according  to  the  constitution,  strength,  age,  and 
habits  of  the  patient.  In  the  young  and  robust,  more  especially  when 
it  is  produced  directly  by  excessive  drinking,  it  often  assumes  a  form 
exceedingly  resembling  that  of  delirium  arising  from  sudden  congestion 
or  inflammation  of  the  brain  or  its  membranes,  and  then  demands 
strictly  antiphlogistic  measures,  such  as  venesection,  leeching,  cold  to 
the  head,  and  very  active  cathartics.  These  remedies  wiU  often  speedily 
arrest  the  progress  of  the  disease.  On  the  other  hand,  we  most  fre- 
quently meet  with  delirium  tremens  calHng  for  a  totally  opposite  plan ; 
for  W'hen  it  occurs  in  the  old,  debilitated,  and  confirmed  drunkard,  who 
has  been  repeatedly  subject  to  its  attacks,  we  are  obliged  to  exhibit 
opium  from  the  very  commencement,  and  that  in  large  doses,  combined 
with  porter,  punch,  or  some  other  cordial.  These  two  form  the  ex- 
tremes, between  which  there  are  many  intermediate  varieties,  each 
requiring  a  special  modification  of  practice. 

Thus,  some  must  be  treated  rather  actively,  on  the  antiphlogistic  plan 
at  first,  and  immediately  afterwards  opiates  may  be  used  with  advantage ; 
while  in  others,  opiates  cannot  be  given  alone  at  any  period  of  the 
disease,  so  prominently  marked  are  the  sjTuptoms  of  cerebral  congestion ; 
and  yet  these  cases  cannot  be  cured  without  narcotics.  How  then  are 
they  to  be  exhibited  ?  Do  we  possess  any  medicine  capable  of  modify- 
ing and  diminishing  their  injurious  effects  when  given  where  cerebral 
congestion  exists  ?  Undoubtedly  w^e  do ;  tartar  emetic  will  often  ac- 
comphsh  this  desirable  object,  and  in  dehrium  tremens  the  value  of  its 
combination  with  opium  is  recognized  by  every  practitioner  of  expe- 
rience. Tartar  emetic,  boldly  exhibited;  is  often  our  sheet  anchor 
in  dehrium  tremens,  especially  when  the  evidence  of  active  determina- 
tion to  the  head  is  undoubted.  Then  tartar  emetic  alone,  in  repeated 
doses,  often  powerfully  contributes  to  produce  tranquiUity  and  sleep ; 
but  there  are  other,  more  mixed  cases,  where  we  cannot  cure  without 
adding  opium,  sometimes  in  larger,  sometimes  in  smaller  quantities,  to 
the  solution  of  tartar  emetic ;  and  so  it  is  with  the  delirium  and  sleep- 
lessness, so  often  met  with  in  continued  fever. 

Every  one  is  acquainted  with  the  indications  denoting  the  propriety 
of  adopting  the  antiphlogistic  practice  when  these  symptoms  make  their 
appearance  in  the  commencement  of  fever.  Then  the  lancet,  leeches, 
purgatives,  cold  applications  to  the  head,  and  finally,  repeated  doses  of 
tartar  emetic  tend  powerfully  to  reduce  vascular  action,  and  diminish 


206  CLINICAL   MEDICINE. 

the  violence  of  symptoms  depending  on  cerebral  congestion  and  excite- 
ment. Here  the  lancet  and  tartar  emetic  are  our  best  opiates,  our  best 
restoratives  of  tranquillity  and  sleep.  As  the  fever  progresses,  and 
when  we  have  arrived  at  a  more  advanced  stage  of  the  disease,  when 
maculae  make  their  appearance  on  the  skin,  and  symptoms  of  general 
debility  announcing  the  typhoid  type  begin  to  predominate,  then  we 
must  proceed  with  more  caution,  even  though  our  patient  is  totally  de- 
prived of  sleep  and  is  violently  delirious.  The  lancet  cannot  now  be 
resorted  to ;  leeches,  indeed,  may  be  applied,  but  their  effects  must  be 
carefully  watched,  as  the  patient  will  not  bear  copious  depletion  of  any 
sort ;  tartar  emetic  may,  nevertheless,  be  still  given  boldly,  and  will  be 
found  to  answer  our  expectations. 

But  if  we  have  to  contend  with  want  of  sleep  and  delirium  at  a  still 
more  advanced  period  of  fever,  we  now  often  recognize  that  very  com- 
bination of  symptoms — the  union  of  general  debihty  and  cerebral  con- 
gestion, which  in  certain  varieties  of  delirium  tremens  we  have  seen  so 
successfully  treated  with  tartar  emetic  and  opium ;  who  will  refuse  to 
acknowledge  the  similarity  between  these  cases  of  fever  delirium  and 
many  varieties  of  delirium  tremens  ?  Are  there  not  in  both,  the  same 
tremor  and  subsultus  of  the  extremities ;  the  same  trembling  of  the 
tongue  when  the  patient  endeavours  to  put  it  out ;  the  same  starting 
and  sleeplessness;  the  same  rambling  delirium  or  incoherence,  com- 
bined nevertheless  with  the  power  of  answering  rationally  when  spoken 
to ;  the  same  character  of  the  mental  wandering,  for  in  both  they  are 
extremely  apt  to  rave  as  if  employed  in  their  ordinary  occupations,  and 
as  if  surrounded  with  their  usual  associates  ;  in  short,  can  any  greater 
resemblance  exist  between  two  diseases  arising  from  the  operation  of 
remote  causes  so  different  ?  We  need  not,  therefore,  be  suprised,  at  find- 
ing the  same  treatment  applicable  to  both. 


207 


LECTUEE  XVII. 


THE    USE    OF   TARTAR    EMETIC    AND    OPIUM    IN   EEVER,    CONTINUEb. 

In  my  last  lecture  I  alluded  to  tlie  peculiar  narcotic  power  of  tlie  pre- 
parations of  antimony,  and  dwelt  on  the  benefits  derived  from  a  combi- 
nation of  antimonials  with  tliose  medicines  which  are  strictly  termed 
narcotics.  I  told  you  in  that  lecture  that  the  good  effects  of  tartar 
emetic  in  delirium  tremens  seem  to  be  totally  independent  of  its  action 
on  the  stomach  ;  for  we  had  witnessed  those  effects  when  it  had  not  ex- 
cited either  nausea  or  vomiting.  I  referred  also  to  many  instances 
of  delirium  tremens,  in  which  opium  in  every  form  had  failed  in  pro- 
curing sleep,  and  where  a  combination  of  tartar  emetic  and  laudanum  had 
succeeded  in  tranquillising  the  patient  and  producing  sound,  refreshing 
sleep.  Bearing  this  important  fact  in  mind,  we  shall  proceed  to  a  fur- 
ther examination  of  the  circumstances  which  require  the  use  of  tartar 
emetic  in  fever. 

There  is  a  peculiar  stage  in  one  form  of  fever,  and  that  exceedingly 
dangerous  and  threatening,  in  which  I  have  derived  most  signal  benefit 
from  the  use  of  this  remedy.  A  patient,  suppose,  gets  an  attack  of 
fever,  he  has  all  the  ordinary  symptoms,  as  thirst,  restlessness,  heat  of 
skin,  quick  pulse,  and  headache.  You  are  called  in  about  the  third  or 
fourth  day,  and  find  that  he  has  all  the  symptoms  I  have  mentioned 
still  present ;  his  face  is  flushed,  his  head  aching,  his  pulse  from  100  to 
110,  but  not  remarkably  strong;  you  find,  also,  that  he  has  been 
sweating  profusely  from  the  commencement  of  his  illness,  but  without 
any  proportionate  relief  to  his  symptoms,  and  that  he  is  restless  and 
watchful.  You  are  informed  that  his  perspirations  are  so  great  that  his 
linen  has  to  be  changed  frequently  in  the  day,  and,  that,  notwithstand- 
ing this,  the  pulse  has  not  come  down,  the  headache  is  undiminished, 
and  the  patient  has  become  more  and  more  sleepless.  Here  comes  a 
very  important  practical  question.     How  are  you  to  treat  'such  a  case  ? 


ii08  CLINICAL   MEDICINE. 

The  patient  has  no  epigastric  tenderness^  no  cough,  no  sign  of  local 
disease  in  either  the  thoracic  or  abdominal  cavities ;  he  has  been  purged, 
taken  diaphoretics,  and  perhaps  mercurials ;  every  attention  has  been 
paid  to  regimen,  ventilation,  and  cleanliness  ;  but  still  he  lies  there  in 
a  state  of  undiminished  febrile  excitement,  with  persistent  headache, 
quickness  of  pulse,  and  sleeplessness. 

In  such  a  case  as  this  you  have  nothing  to  expect  from  sweating  ; 
it  will  never  produce  any  relief.  I  was  called  some  time  back  to  see  a 
young  gentleman  in  fever,  who  was  placed  in  similar  circumstances  to 
those  which  I  have  just  detailed.  It  was  about  the  sixth  day  of  his 
fever,  and  I  found  him  with  a  pulse  of  about  110,  with  considerable  rest- 
lessness and  headache,  and  was  informed  that  he  had  perspired  profusely 
from  the  commencement  of  his  illness.  On  hinting  the  necessity  of 
more  active  treatment  than  that  which  had  been  employed,  his  physi- 
cians appealed  to  the  perspirations  as  decidedly  contra-indicating  deple- 
tion. They  said  that  the  profuse  sweating  pointed  out  the  impropriety 
of  active  measures,  and  that  it  was  a  symptom  which  would  be  speedily 
followed  by  relief.  I  was  convinced  that  they  had  taken  a  wrong  view 
of  the  case,  and  stated  as  my  opinion  that  nothing  was  to  be  expected 
from  the  perspirations ;  that  when  co-existing  with  a  persistent  febrile 
condition  of  the  system,  when  accompanied  by  quick  pulse,  headache, 
and  restlessness,  perspirations  always  indicated  the  necessity  for  anti- 
phlogistic measures,  and  in  particular  for  the  use  of  the  lancet.  I  in- 
stanced the  case  of  patients  labouring  under  arthritis  with  profuse  per- 
spirations which  gave  no  relief,  and  said  that  it  was  well  known 
that  such  cases  were  most  successfully  treated  by  a  full  bleeding  from 
the  arm.  I  accordingly  stated  that  although  the  disease  was  of  five  or 
six  days'  standing,  and  the  pulse  not  very  strong,  I  would  advise  imme- 
diate bleeding.  Sixteen  ounces  of  blood  were  therefore  abstracted,  with 
some  relief  to  the  patient;  and  without  increasing  his  debility ;  and  it 
was  then  a  question  what  further  steps  were  to  be  taken. 

The  young  gentleman  had  been  actively  purged ;  he  had  no  cough 
nor  abdominal  tenderness ;  his  symptoms  were  headache,  sweating,  and 
sleeplessness ;  and  to  these,  nervous  agitation  had  now  become  super- 
added. I  proposed  here  what  surprised  my  colleagues  very  much,  and 
this  was,  to  give  our  patient  large  doses  of  tartar  emetic.  They  said  the 
practice  was  very  strange,  but  on  my  laying  before  them  the  reasons  which 
induced  me  to  prescribe  it,  consented  to  give  it  a  trial.  I  said  that 
in  such  cases  the  tartar  emetic,  forming  as  it  were  a  part  of  the  anti- 
phlogistic treatment  which  commenced  with  general  bleeding,  would 
have  a  tendency  to  cut  short  instead  of  increasing  the  perspiration,  by 
reducing  the  inflammatory  state  of  the  system  on  which  it  depended. 


\ 


TARTAR   EMETIC    IN    FEVER.  20$ 

The  reasoning  seemed  rather  paradoxical — nevertheless  it  turned  out  to 
be  correct.  I  ordered  the  tartar  emetic  to  be  taken  in  the  quantity  and 
mode  in  which  it  is  generally  prescribed  in  acute  pneumonia ;  that  is  to 
say,  six  grains  of  tartar  emetic  combined  with  a  little  mucilage  and 
cinnamon  water  in  an  eight  ounce  mixture,  to  be  taken  in  the  course  of 
twenty-four  hours.  After  taking  five  or  six  grains,  the  sweating  began  to 
diminish ;  on  the  second  day  he  scarcely  perspired  any,  and  his  head- 
ache was  greatly  reheved ;  he  began  to  improve  rapidly  in  every  respect, 
sleep  returned,  nervous  agitation  ceased,  and  convalescence  became  soon 
established. 

The  next  case  in  which  I  employed  tartar  emetic  with  signal  benefit 
was  one  of  a  very  insidious  character,  as  many  of  them  are  at  present ; 
they  exhibit  no  prominent  or  alarming  symptoms,  and  yet  continue  to 
run  on  day  after  day  without  any  tendency  to  crisis.  The  gentleman 
who  was  the  subject  of  this  case  got  an  attack  of  fever,  unaccompanied 
by  any  remarkable  peculiarity,  except  that  he  was  very  nervous,  and 
alarmed  about  his  situation.  His  fever  went  on  day  after  day  without 
any  decided  symptom ;  he  had  no  distressing  headache,  no  cough,  little 
or  no  abdominal  tenderness;  there  was  no  vomiting  nor  diarrhoea; 
and  his  pulse  was  not  much  above  the  natural  standard.  He  had 
been  leeched  over  the  stomach  at  the  suggestion  of  some  medical  friends, 
but  this  was  done  rather  by  the  way  of  precaution  than  for  the  purpose 
of  combating  any  actual  disease.  About  the  eighth  or  ninth  day  the 
pulse  began  to  rise ;  he  complained  of  headache,  and  became  restless 
and  watchful.  On  the  eleventh  day  the  headache  had  greatly  increased, 
he  was  in  a  state  of  great  nervous  excitement,  and  had  not  closed  an 
eye  for  the  two  preceding  days  and  nights.  This  state  of  insomnia  and 
nervous  agitation  was  immediately  followed  by  violent  paroxsyms  of 
delirium;  his  eyes  never  closed  in  sleep,  wandered  from  object  to 
object  with  unmeaning  restlessness ;  his  limbs  were  in  a  state  of  constant 
jactitation,  and  he  raved  incessantly  ;  his  voice  being  occasionally  loud 
and  menacing,  at  other  times  low  and  muttering.  His  friends  became 
exceedingly  alarmed,  and  every  remedy  which  art  could  suggest  was 
tried: — his  head  was  shaved  and  leeched  until  they  could  leech  no 
longer;  cold  lotions  were  kept  constantly  applied  with  unremitting 
diligence,  and  he  was  purged  freely  and  repeatedly. 

At  this  period,  that  is  to  say,  about  the  eleventh  day  of  the  fever,  I 
was  requested  by  this  gentleman's  medical  friends  to  visit  him.  On 
examining  the  patient,  I  found  that  he  was  constantly  making  violent 
efforts  to  rise  from  his  bed,  and  that  he  had  a  great  deal  of  the  expres- 
sion of  countenance  which  belongs  to  a  maniacal  patient.  Under  these 
circumstances,  I  advised  the  use  of  large  doses  of  tartar  emetic,  in  the 
VOL.  I.  14 


aiO  CLINICAL   MEDICINE. 

mode  already  detailed,  except  that,  in  this  case,  in  consequence  of  the 
violence  of  the  delirium,  I  ordered  the  quantity  prescribed  for  a  dose  to 
be  taken  every  hour  instead  of  every  second  hour.  The  patient  took 
about  ten  or  twelve  grains  during  the  course  of  the  night,  and  next  day 
his  delirium  had  almost  completely  subsided.  Under  the  use  of  the 
remedy  he  became  quite  calm,  fell  into  a  sound  sleep,  and  began  to 
recover  rapidly. 

In  the  two  preceding  cases  I  was  guided  by  ordinary  principles, 
recognised  by  all  physicians,  and  according  to  which  the  exhibition  of 
tartar  emetic  is  recommended  in  fever,  wherever  there  is  undoubted 
evidence  of  determination  of  blood  to  the  head,  producing  headache, 
loss  of  sleep,  and  dehrium.  In  the  cases  which  follow,  tartar  emetic 
was  exhibited  at  a  period  of  fever,  and  under  circumstances  that  were, 
with  respect  to  the  exhibition  of  this  remedy,  not  less  novel  than 
important.  The  principles  which  led  me  to  this  practice  have  long 
been  established,  but,  nevertheless,  the  practice  is  entirely  new,  and  (I 
say  it  with  pride  for  it  abeady  has  been  the  means  of  saving  many  va- 
luable lives)  it  is  entirely  my  own. 

Shortly  after  the  commencement  of  our  present  session,  Mr.  Cookson, 
a  pupil  at  this  hospital,  and  remarkable  for  his  diligent  attention  to 
clinical  pursuits,  caught  fever  while  attending  our  wards,  in  which 
many  cases  of  the  present  epidemic  were  then  under  treatment.  His 
fever  was  of  an  insidious  nature,  not  characterised  by  any  prominent 
symptom,  not  exhibiting  any  local  disease  to  combat,  or  any  tendency 
to  crisis.  Tor  the  first  seven  or  eight  days,  with  the  exception  of  head- 
ache, which  was  much  relieved  by  leeching,  he  seemed  to  be  going  on 
very  well ;  his  skin  was  not  remarkably  hot ;  he  had  no  great  thirst, 
nausea,  or  abdominal  tenderness ;  his  pulse  was  only  85  ;  and  he  had 
sweating,  which  was  followed  by  some  relief.  About  the  eight  or  ninth 
day  the  pulse  rose,  and  he  began  to  exhibit  symptoms  of  an  hysteric 
character.  Now,  in  every  case  of  fever,  where  symptoms  resembling 
those  of  hysteria  come  on,  you  should  be  apprehensive  of  danger. 
I  do  not  recollect  having  ever  met  with  a  single  case  of  this  kind  which 
did  not  terminate  in  nervous  symptoms  of  the  most  formidable  nature. 

I  prescribed  at  the  time  the  usual  anti-hysteric  medicines,  but  with- 
out any  hope  of  doing  good,  knowing  that  these  symptoms  were  only 
precursory  to  something  worse.  I  also,  as  a  precautionary  measure,  had 
leeches  appUed  to  his  head.  The  fever  went  on,  the  headache  became 
more  intense ;  he  grew  nervous  and  sleepless,  and  fell  into  a  state  of 
great  debility.  On  the  fourteenth  day  of  fever  his  tongue  was  black 
and  parched,  his  belly  tympanitic;  he  was  passing  everything  under 
him  unconsciously ;  he  had  been  raving  for  the  last  four  days,  con- 


TARTAR  EMETIC  AND  OPIUM  IN  FEVER.  2]  1 

stantly  attempting  to  get  out  of  bed,  and  had  not  slept  a  single  hour 
for  five  days  and  nights. 

Dr.  Stokes,  with  his  usual  kindness,  gave  me  the  benefit  of  his  advice 
and  assistance  at  this  stage  of  Mr.  Cookson's  illness,  and  we  tried  every 
remedy  which  experience  could  suggest.  Blisters  were  applied  to  the 
nape  of  the  neck,  the  head  was  kept  cool  by  refrigerant  lotions,  the 
state  of  the  belly  attended  to,'  and,  as  we  perceived  that  the  absence  of 
sleep  was  a  most  prominent  and  distressing  symptom,  we  were  induced 
to  venture  on  the  cautious  use  of  opium.  It  was  first  given  in  the 
form  of  Dover's  powder,  with  hydragyrum  cum  creta,  with  the  view  of 
reheving  the  abdominal  symptoms  as  well  as  procuring  sleep.  This 
failing  in  producing  the  desired  effect,  we  gave  opium  in  the  form  of 
enema,  knowing  its  great  power  in  the  delirium  which  follows  wounds 
and  other  injuries.  This  was  equally  unsuccessful  with  the  former. 
He  still  was  perfectly  sleepless.  We  came  again  in  the  evening,  and, 
as  a  last  resource,  prescribed  a  full  dose  of  black  drop,  and  left  him 
with  the  conviction  that  if  this  failed  he  had  no  chance  of  life. 

On  visiting  him  next  morning  at  an  early  hour,  we  were  highly 
mortified  to  find  that  our  prescription  had  been  completely  unsuc- 
cessful ;  he  had  been  more  restless  and  delirious  than  ever.  Here  was 
the  state  in  which  we  found  him  on  entering  his  chamber  at  eight 
o'clock  in  the  morning  of  the  fifteenth  day  of  his  fever.  He  had 
universal  tremors  and  subsultus  tendinum,  his  eye  was  suffused  and 
restless,  he  had  been  lying  for  some  days  entirely  on  his  back,  his 
tongue  was  dry  and  black,  liis  belly  tympanitic,  his  pulse  140,  quick 
and  thready,  his  delirium  was  cliiefly  exhibited  in  short  broken  sen- 
tences and  in  a  subdued  tone  of  voice ;  and  it  was  now  eight  days  and 
nights  since  he  had  slept.  Here  arose  a  question  of  great  practical 
importance.  How  was  the  nervous  agitation  to  be  calmed  and  sleep 
produced?  Bhsters  to  the  nape  of  the  neck,  cold  applications,  and 
purgatives  had  failed ;  opium  in  various  forms  had  been  tried  without 
the  slightest  benefit ;  if  sleep  were  not  speedily  obtained  he  was  lost. 

At  this  emergency  a  mode  of  giving  opium  occurred  to  me  which  I 
had  never  thought  of  before.  EecoUect  what  his  symptoms  were  at 
this  period  :  quick,  failing  pulse,  black,  dry,  tremulous  tongue,  great 
tympanitis,  excessive  prostration  of  strength,  subsultus  tendinum,  ex- 
treme nervous  agitation,  constant  muttering,  low  delirium,  and  total 
sleeplessness.  I  said  to  Dr.  Stokes  that  I  wished  to  try  what  effects 
might  result  from  a  combination  of  tartar  emetic  and  opium ;  I  men- 
tioned that  I  had  given  it  in  cases  of  delirium  tremens  with  remarkable 
success,  and  thought  it  worthy  of  trial  under  the  circumstances,  then 
present.     Dr.  Stokes  stated  in  reply,  that  he  knew  nothing '  with  re- 


212  CLINICAL   MEDICINE. 

spect  to  such  a  combination  as  adapted  to  the  case  in  question,  that  he 
had  no  experience  to  guide  him,  but  that  he  would  yield  to  my  sugges- 
tion. We  therefore  prescribed  a  combination  of  tartar  emetic  and 
laudanum  in  the  following  form,  which  is  that  in  wliich  I  generally 
employ  the  remedies  in  the  treatment  of  delirium  tremens  :  Tartar 
emetic,  four  grains ;  tincture  of  opium,  a  drachm ;  camphor  mixture, 
eight  ounces;  mix.  Of  this  mixture,  a  tablespoonful  to  be  taken 
every  second  hour.  The  success  of  this  was  almost  magical.  It  is  true 
that  it  vomited  him ;  after  taking  the  second  dose  he  threw  up  a  large 
quantity  of  bile,  but  it  did  him  no  harm.  After  the  third  or  fourth 
dose  he  fell  asleep,  and  awoke  calm  and  refreshed.  He  began  to  im- 
prove rapidly,  and  soon  recovered. 

The  next  case  to  which  I  shall  direct  your  attention  is  that  of  Mr. 
Stephenson,  a  pupil  of  Mr.  Parr  of  this  hospital.  This  young  gentleman, 
as  many  of  you  may  recollect,  was  attacked  with  fever  about  the  middle 
of  January.  On  Thursday  evening  he  complained  of  languor  and  ma- 
laise, and  on  the  following  day  felt  himself  feverish,  but  without  any 
prominent  or  decided  symptom.  At  night  he  took  a  dose  of  calomel 
and  antimonial  powder,  which  had  no  sensible  effect,  and  the  following 
day  complained  of  shivering,  violent  headache,  pain  in  the  back,  thirst, 
prostration  of  strength,  and  sleeplessness.  Hs  was  ordered  to  take  a 
combination  of  tartar  emetic  and  nitrate  of  potash  in  camphor  mixture, 
which  produced  a  few  loose  stools  and  some  diaphoresis ;  but  in  conse- 
quence of  its  effect  on  the  stomach,  and  his  complaining  much  of  thirst 
and  epigastric  tenderness,  the  tartar  emetic  was  omitted,  and  efferves- 
cing draughts  prescribed.  Two  days  afterwards,  the  epigastric  tender- 
ness still  continuing,  twelve  leeches  were  applied  over  the  pit  of  the 
stomach,  followed  by  a  blister,  wliich  gave  relief,  and  the  bowels  were 
kept  open  by  enemata. 

He  commenced  a  second  time  the  use  of  the  tartar  emetic  and  nitrate 
of  potash,  with  the  addition  of  five  drops  of  tincture  of  opium  to  each 
dose,  but  was  obliged  to  give  it  up  again  in  consequence  of  the  increase 
in  his  gastric  symptoms.  He  now  became  exceedingly  restless,  and  his 
delirium  began  to  assume  a  very  intense  character.  Leeches  were  ap- 
phed  behind  the  ears,  his  head  shaved,  and  his  temples  blistered ;  he 
had  also  a  large  blister  over  the  abdomen,  which  gave  him  considerable 
rehef,  but  the  cerebral  and  nervous  symptoms  became  much  worse. 
The  delirium  went  on  increasing,  accompanied  by  subsultus  tendinum, 
and  picking  the  bed-clothes ;  he  was  perfectly  sleepless ;  raved  inces- 
santly, and  had  to  be  kept  down  in  bed  by  force.  On  the  17  th 
day  of  his  fever  he  was  in  the  following  condition — tongue  brown  and 
rather  dry,  no  remarkable  thirst  nor  abdominal  tenderness,  eyes  red 


TARTAR   EMETIC    AND    OPIUM    IN    FEVER.  213 

and  ferrety,  no  sleep  for  five  nights,  constant  muttering  and  delirium, 
(which  had  now  assumed  the  character  of  delirium  tremens,)  subsultus 
tendinum  and  jactitation  extreme,  urine  and  faeces  passed  under 
him  unconsciously.  I  directed  the  combination  of  tartar  emetic 
and  laudanum  to  be  immediately  given,  carefully  watching  its  effects. 
He  had  only  taken  two  doses  when  a  degree  of  calmness  set  in,  bringing 
with  it  relief  to  all  his  symptoms,  and  before  a  third  dose  could  be 
administered,  he  fell  into  a  profound  sleep,  from  which  he  awoke 
rational  and  refreshed.  The  mixture  was  continued  every  four  hours 
with  increasing  benefit,  he  slept  long  and  soundly,  and  began  to  im- 
prove in  every  respect.  On  the  second  day  after  he  had  begun  to  use 
the  tartar  emetic,  he  took  a  little  porter,  which  was  changed  the  next 
day  for  claret  and  chicken  broth.  In  about  a  week  he  was  able  to  sit 
up  in  bed,  and  seven  days  afterwards  was  able  to  leave  the  hospital  and 
go  to  the  country  for  change  of  air. 

Another  case  to  which  I  shall  direct  your  attention  is  that  of  Mr. 
Knott,  also  a  pupil  of  this  hospital,  a  gentleman  remarkable  for  his  un- 
remitting attention  to  cKnical  pursuits,  and  from  whom  I  derived  much 
valuable  assistance  in  conducting  various  post-mortem  examinations. 
This  gentleman  was  attacked  with  fever  about  the  latter  part  of  January, 
which  went  on  for  some  time  without  any  particular  symptom,  except 
considerable  restlessness  and  nervous  excitement.  He  then  became  per- 
fectly sleepless,  complained  of  violent  headache  and  thirst,  raved,  and 
became  exceedingly  irritable.  Opium  in  various  forms  and  repeated 
doses,  either  alone,  or  combined  with  musk  and  camphor,  totally  failed 
in  producing  sleep,  and  his  condition  became  daily  w^orse.  On  the  13th 
day  he  was  in  a  very  dangerous  condition ;  his  nervous  agitation  had 
risen  to  an  alarming  height,  and  for  many  days  and  nights  he  had  never 
closed  an  eye.  At  this  period  it  appeared  obvious  that  if  something 
were  not  done  to  calm  nervous  excitement  and  restore  sleep,  he 
had  but  little  chance  of  life.  Under  these  circumstances  I  proposed 
to  Dr.  M'Adam,  who  attended  with  me,  to  give  tartar  emetic  and 
opium.  After  he  had  taken  about  three  tablespoonfuls,  he  had  a 
copious  biKous  evacuation,  and  immediately  afterwards  fell  into  a  sound 
sleep,  during  which  he  perspired  profusely,  and  awoke  in  about  twelve 
hours,  with  every  bad  symptom  gone.  The  nervous  irritability  was 
completely  allayed ;  his  thirst  and  headache  relieved ;  liis  tongue  moist 
and  cleaning ;  and  his  reason  quite  restored.  From  that  period  every 
thing  went  on  favourably,  and  he  rapidly  gained  his  health  and  strength. 

In  many  other  cases  of  fever,  I  have  recently  employed  the  tartar 
emetic  and  opium  with  the  same  remarkable  success.  A  man  named 
Christopher  Nowlan  was  admitted  into  Sir  Patrick  Dun's  Hospital,  on 


214j  clinical  medicine. 

the  3rd  of  February,  labouring  under  fever.  He  had  been  ill  ten  days, 
had  raving,  subsultus  tendinum,  and  appeared  unable  or  unwilling  to 
answer  questions.  His  wife  stated  that  he  had  diarrhoea  for  the  pre- 
ceding three  days,  and  that  he  dozed  occasionally,  but  never  slept.  He 
appeared  exceedingly  low  and  prostrated,  and  lay  constantly  on  his  back. 
A  succession  of  flying  blisters  was  ordered  to  be  apphed  to  the  chest 
and  stomach,  and  wine  and  chicken  broth  prescribed.  He  also  got  the 
following  draught  every  tliird  hour  : — 

Bi.  Misturse  Camphorae,  f^j. 
Spiritus  ^theris  oleosis,   f3s 
Spiritus  Ammonise  aromatici,  f3ss. 
Moschi,  gr.  viij — Misce. 

Under  the  use  of  these  remedies  he  began  to  recover  from  his  prostra- 
tion ;  but  as  the  sleeplessness  and  delirium  still  continued,  I  ordered 
him  to  take  the  tartar  emetic  mixture  in  the  usual  way.  It  produced 
at  first  two  or  three  fuU  discharges  from  the  bowels,  and  after  he  had 
taken  the  fourth  dose  he  fell  into  a  sound  sleep,  from  which  he  awoke 
much  better,  and  soon  became  convalescent. 

In  the  case  of  a  patient  named  Michael  Murray,  who  exhibited  the 
same  remarkable  nervous  irritabihty  and  sleeplessness,  this  remedy  was 
also  employed  with  very  striking  effects.  This  man  had  been  ill  of  fever 
for  ten  days  before  his  admission  into  Sir  Patrick  Dun's  Hospital,  and 
appeared  so  much  prostrated  that  I  ordered  him  arrowroot  with  beer. 
He  raved  a  little  on  the  night  of  his  admission,  and  remained  with- 
out closing  an  eye  until  morning.  The  same  symptoms  were  observed 
on  the  following  day,  and  his  nervous  irritability  became  increased.  On 
the  14th  of  February  he  had  been  five  days  in  the  hospital,  and  had  not 
enjoyed  a  single  hour's  sleep.  I  ordered  the  tartar  emetic  mixture  to 
be  given  :  three  doses  produced  sleep  :  he  had  no  other  bad  symptoms, 
and  recovered  completely. 

In  another  very  bad  case  of  maculated  fever,  the  same  results  were 
obtained.  The  patient,  Mary  Farmin,  had  got  an  attack  of  fever  after 
a  fright.  She  had  been  eight  days  iU  at  the  date  of  her  admission,  Fe- 
bruary 25th.  She  had  irregular  pulse,  sleeplessness,  headache,  and 
suffusion  of  the  eyes ;  moaned  and  sighed  continually,  and  appeared 
greatly  prostrated.  She  was  bhstered,  had  fetid  enemata,  and  took  the 
chloride  of  soda  internally  with  some  benefit ;  but  the  sleeplessness  and 
nervous  excitement  continued.  In  this  case,  though  the  tartar  emetic 
was  not  followed  by  speedy  convalescence,  still  it  produced  remarkably 
good  effects ;  after  taking  four  doses  of  it  she  fell  asleep,  and  did  not 
awake  until  next  morning. 


TARTAR    EMETIC    AND    OPiUM  IN  FEVER.  215 

Several  other  cases  have  occurred  both  iu  hospital  and  private  prac- 
tice, to  some  of  which  I  now  beg  leave  to  direct  your  attention,  ob- 
serving that  I  have  in  every  instance  been  particular  in  mentioning  the 
names  of  other  professional  gentlemen  who  witnessed  the  progress  of 
each  case :  a  precaution  tending  to  prevent  exaggeration  either  in  de- 
tailing symptoms  or  describing  the  effects  of  remedies. 

The  case  of  Mr.  WilHam  Murphy,  an  extremely  diligent  and  intelli- 
gent pupil  at  the  Meath  Hospital  is  well  worthy  of  notice.  The  father 
of  this  gentleman,  a  practitioner  of  well-known  reputation  at  Permoy, 
where  he  has  been  Physician  to  the  Tever  Hospital  for  many  years,  ar- 
rived in  Dublin  the  very  day  his  son's  state  appeared  to  be  hopeless, 
soon  after  the  consultation,  when  Dr.  Stokes  and  I  agreed  to  use  the 
tartar  emetic  and  opium ;  Doctor  Murphy  admitted  afterwards  that  he 
never  felt  so  much  surprised  as  he  was  at  this  treatment,  but  having 
entrusted  the  care  of  his  son  to  us,  he  very  properly  expressed  no 
opinion  on  the  subject,  a  mode  of  proceeding  he  has  never  since  ceased 
to  congratulate  himself  on,  for  had  he  opposed  us,  the  case  was  appar 
rently  so  desperate,  that  it  may  be  doubted  whether  we  would  have  ven- 
tured to  put  the  plan  into  execution. 

Mr.  Murphy,  aged  20,  having  been  engaged  in  the  diligent  study  of 
the  fever  cases  in  the  Meath  Hospital,  was  attacked  with  violent  symp- 
toms of  fever  on  the  6th  of  January  last.  He  took  a  dose  of  calomel 
and  James's  powder,  and  went  to  bed ;  early  next  morning  he  was  worse, 
and  although  he  took  a  purgative  draught  which  operated  freely  on  the 
bowels,  he  complained  much  of  headache,  and  was  very  feverish;  a 
copious  sweat  broke  out,  but  was  unattended  with  relief,  notwithstand- 
ing that  it  continued  with  more  or  less  interruption  for  several  days. 
His  thirst  was  excessive,  and  he  was  very  restless,  depressed,  weak,  and 
nervous ;  the  antimonial  powder  and  calomel  were  persevered  in  during 
the  second  day,  and  on  the  third  he  took  more  purgative  mixture,  and 
twelve  leeches  were  applied  to  the  temples,  but  they  gave  little  or  no 
relief  to  the  pain  in  the  head. 

In  short,  he  grew  worse,  and  was  found  to  be  extremely  prostrated. 
On  the  4th,  his  tongue  was  foul  and  dry,  his  stomach  irritable,  often 
rejecting  his  medicine,  and  producing  a  vomiting  of  bilious  matter,  the 
pulse  quick,  and  his  appearance  unpromising.  I  saw  him  on  the  5th  day, 
when  every  thing  was  still  worse,  and  the  pain  of  head  much  complained 
of.  I  directed  a  continuation  of  the  James's  powder,  and  effervescing 
draughts.  On  the  6th  day  he  was  still  worse,  and  was  reported  to  have 
raved  a  good  deal  during  the  night ;  liis  bowels  were  loose,  and  now  for 
the  first  time  the  perspiration  entirely  ceased,  and  his  skin  became  hot 
and  dry.     I  gave  him  small  doses  of  Dover's  powder  and  chalk.     On 


216  CLINICAL  MEDICINE. 

the  7th  day,  his  countenance  expressed  great  anxiety,  and  in  addition 
to  an  aggravation  of  all  the  other  symptoms,  his  skin  became  covered 
with  a  measles  like  eruption  of  maculae,  a  circumstance  which  induced 
me  to  give  the  solution  of  cliloride  of  soda,  in  doses  of  twelve  drops, 
every  fourth  hour,  in  an  ounce  of  camphor  mixture.  He  got  mild  diet, 
as  arrow  root  and  chicken  broth,  with  a  Httle  stale  bread  sopped  in  tea, 
night  and  morning.  On  the  8th  day,  no  improvement ;  much  raving 
during  the  night,  symptoms  as  before,  except  that  the  occurrence 
of  some  abdominal  tympanitis  and  shght  epigastric  tenderness  in- 
duced me  to  apply  six  leeches  to  the  pit  of  the  stomach.  The 
bleeding  from  the  leech  bites  was  moderate,  but  seemed  nevertheless  to 
exhaust  him.  It  seemed  to  check  the  tympanitic  tendency.  On  the 
9th  day,  was  still  worse,  much  stupor,  incipient  subsultus;  towards 
evening  a  very  hurried  and  laboured  breathing  supervened,  and  he  lay 
entirely  on  liis  back,  helpless  and  weak,  respiring  about  45  times  in  a 
minute.  As  he  had  not  the  slightest  affection  of  the  lungs  or  bronchial 
tubes,  this  hurried  breathing  excited  the  greatest  alarm  in  my  mind, 
and  induced  me  to  apply  six  leeches  behind  the  ear,  with  a  view 
of  reheving  the  now  increasing  stupor,  and  the  evident  cerebral  con- 
gestion. 

On  the  10th  day,  I  had  the  benefit  of  Dr.  Stokes'  advice.  We 
found  our  patient  in  a  state  truly  appalling.  He  lay  panting  on  his 
back,  restless  and  without  sleep,  every  muscular  fibre  in  his  face  and 
limbs  was  agitated  with  spasmodic  twitches,  giving  rise  to  the  greatest 
possible  degree  of  subsultus,  which  distorted  his  face,  caused  him  to 
bite  his  under  lip  every  instant,  rendered  him  quite  unable  to  put  out 
his  tongue,  although  he  endeavoured  to  do  so.  The  subsultus  prevented 
us  from  being  able  to  feel  the  pulse,  now  weak  and  rapid,  at  the  wrist. 
In  the  mean  time,  though  he  often  moaned  and  raved,  he  muttered  in- 
distinctly ;  he  evidently  understood  what  was  said  to  him,  and  as  far  as 
we  could  collect,  he  seemed  to  suffer  much  less  from  pain  in  his  head. 
Still  the  temporal  arteries  were  turgid,  and  his  eyes  suffused.  He  had 
retention  of  urine,  and  since  yesterday  it  was  drawn  off  with  the  ca- 
theter. 

What  was  now  to  be  done  ?  Cold  lotions  to  the  shaved  head  had 
failed — a  blister  to  the  nape  of  the  neck  had  proved  useless — we  could 
not  venture  to  rely  on  more  blistering  of  the  scalp — some  more  powerful 
remedy  must  be  instantly  brought  to  bear,  or  our  patient  was  lost. 
Alvine  evacuations  had  been  pushed  to  the  fullest  extent ;  leeches  could 
not  even  be  proposed,  so  great  was  the  debility.  Opium  we  dared  not 
venture  on,  seeing  that  so  recently  the  pain  in  his  head  had  been  urgent, 
and  that  the  temporal  arteries  and  the  conjunctiva  still  seemed  to  indi- 


TAETAR   EMETIC   AND    OPIUM    IN    FEVER.  217 

cate  cerebral  congestion ;  under  these  circumstances  we  resolved  to  try 
tartar-emetic^  and  we  ordered  the  following  mixture : — 

I^.    Tartar!  Emetici,  gr.  ii. 
Moschi,  gr.  xxx. 
Mucilaginis, 
Syrupi  simpHcis,  aa^  f§i. 
Aquae,  f^x. 
Misce,  sumat  Bss.  omni  hora. 

After  he  had  taken  about  six  doses  of  this  medicine,  he  seemed  rather 
better,  and  the  symptoms  of  determination  to  the  head  appeared  less 
marked ;  we  therefore  added  fifteen  minims  of  patent  black  drop  to  the 
remaining  nine  ounces  of  the  mixture,  and  directed  small  quantities  of 
porter  and  chicken  broth  to  be  given  repeatedly  during  the  night.  On 
the  11th  day,  we  found  a  change  for  the  better  truly  surprising,  the 
pulse  had  diminished  remarkably  in  frequency,  and  had  become  softer 
and  fuller ;  a  warm  sweat  had  broken  out,  he  had  raved  but  little,  and 
had  slept  tranquilly.  We  ordered  a  continuance  of  the  same  nourish- 
ment and  medicines,  the  latter  at  much  longer  intervals ;  the  case  need 
not  further  be  detailed,  as  Mr.  Murphy  rapidly  recovered  and  enjoyed  a 
speedy  convalescence.  Here  then  is  a  case  which  would  assuredly  have 
been  lost  but  for  the  weU-tried  application  of  the  new  method  of  treat- 
ment. I  say  this  emphatically,  for  Mr.  Glyssan,  Mr.  Boy  ton,  Mr. 
Clarke,  and  Doctor  Murphy,  all  anxious  and  competent  observers,  as- 
sured us  that  from  the  moment  he  began  the  bottle,  its  good  effects  were 
apparent,  and  increased  after  each  dose. 

The  next  case  I  shall  mention  is  that  of  John  Doyle,  admitted  into 
the  Meath  Hospital,  May  21st,  1835  ;  three  or  four  days  ill,  a  strong 
young  man ;  the  symptoms  were  attended  with  considerable  re-action  at 
the  beginning,  his  face  being  flushed,  eyes  wild,  and  head  aching;  he 
raved  much  during  the  night  from  the  4th  day,  and  had  then  a  full 
bounding  pulse  at  105.  Yenesection  was  ordered,  but  he  fainted  when 
four  ounces  of  blood  had  been  drawn.  Leeches  were  then  apphed  to 
the  epigastrium.  On  the  sixth  day  of  his  illness,  his  thirst  was  great, 
no  sleep,  skin  moist,  belly  soft,  pulse  120,  pain  in  head  severe,  copious 
eruption  of  maculae.  His  head  was  now  shaved,  and  six  leeches  applied 
behind  the  ear,  and  repeated  three  times.  He  was  ordered  the  liquor 
of  the  chloride  of  soda  on  the  7th  day,  as  the  vascular  excitement  had 
then  diminished,  and  the  maculse  constituted  a  prominent  feature  in  his 
case.  On  the  Sth  day  he  was  not  worse,  but  liis  skin  was  very  hot. 
On  the  9th  day,  eyes  suffused,  face  flushed,  much  thirst,  no  sleep,  bowels 
free,  belly  soft,  some  epigastric  tenderness,  tongue  loaded,  but  moist : 
cold  lotions  to  the  head.     10th  day,  delirium  violent  during  the  night, 


218  CLINICAL  MEDICINE. 

strait-waistcoat  necessary,  eyes  suffused,  belly  soft,  skin  very  hot,  pulse 
120,  respirations  40,  considerable  subsultus.  Six  leeches  to  be  applied 
behind  the  ear  three  times  successively. 

R  Tartar!  eraetici,  gr.  iv.  ; 

AqujB,  f^xvj.     Misce,  sumat  semiunciara  omni  hora. 

11th.  Slept  very  little,  delirium  less  violent,  one  very  large  stool, 
heat  of  skin  less,  eruption  copious. 

R   Misturae  Oamphorae,  f^viij.  j 
Tartar!  emetici,  gr.  iv.  ; 
Tincturae  Opii,  fSi*  ', 
Misce,  sumat  §ss.  secunda  quaque  hora. 

12th.  Slept  five  hours,  seems  better,  but  still  he  passes  his  stools 
under  him;  pulse  120,  eyes  sufi*used,  skin  hot,  tongue  cleaning,  belly 
soft,  bowels  loose,  maculae  numerous.  The  same  prescription,  except 
that  the  tincture  of  opium  was  increased  to  3iss.  in  the  eight  ounce 
mixture. 

]  3th.  The  medicine  was  continued  for  several  hours,  when  he  fell 
asleep,  and  slept  so  much  and  so  tranquilly,  that  it  was  not  thought 
necessary  to  repeat  it.  Pulse  110;  subsultus  not  near  so  violent; 
does  not  rave ;  knows -every  one,  and  answers  rationally ;  light  nour- 
ishment. 

14th  and  15  th.  Improvement  continues,  but  still  there  is  much 
fever,  and  many  maculae.  About  the  21st  day  he  was  free  from  fever, 
but  he  got  no  medicine  after  the  night  of  the  12th. 

This  case  exemplifies  the  treatment  adapted  to  the  three  different 
stages — 1st,  Bleeding,  leeches,  cold  lotions :  2nd,  Tartar  emetic  in 
large  doses,  combined  with  leeching  :  3rd,  Opium  boldly  administered 
in  combination  with  tartar  emetic. 

The  following,  communicated,  by  Mr.  Knott,  excited  much,  interest 
among  the  practitioners  of  the  neighbourhood  : — 

"  On  the  20th  of  July  last,  I  was  called  to  see  a  comfortable  farmer, 

residing  near  Boyle,  in  the  county  Eoscommon,  named  J.  K .     He 

was  aged  30  years,  and  had  been  iU  21  days.  His  fever  commenced 
with  rigor,  headache,  and  pains  in  the  loins,  the  headache  being  par- 
ticularly severe.  In  the  commencement  of  the  fever  he  had  raved  in- 
cessantly ;  slept  but  little ;  had  frequent  retching ;  his  bowels  were  con- 
fined ;  for  these  symptoms,  he  was  purged  with  black  bottle  to  excess, 
and  bled  largely  and  frequently,  but  without  any  permanent  alleviation. 
On  the  21st  day  of  his  fever  he  presented  the  following  appearance  and 
symptoms  : — his  countenance  was  expressive  of  great  anxiety  and  fero- 
city ;  his  eyes  were  bloodshot  and  wild ;  teeth  covered  with  sordes ; 
tongue  brown  and  fuirowed  with  clefts ;  he  raved  violently  and  attempt- 


TAllTAR  EMETIC  AND  OPIUM  IN  FEVER.  219 

ed  to  get  out  of  the  bed  several  times ;  great  excitement  and  subsul- 
tus;  his  skin  was  very  hot  and  dry ;  all  the  secretions  much  diminished; 
urine  high  coloured ;  no  eruption ;  no  epigastric  tenderness ;  abdomen 
slightly  swollen  and  tympanitic,  but  pressure  seemed  to  give  no  pain ; 
his  bowels  had  not  been  open  for  three  days.  That  night  he  was  or- 
dered 40  drops  of  the  tincture  of  opium,  at  the  same  time  that  an 
enema  was  exhibited;  the  bowels  were  once  opened;  he  slept  none 
during  the  niglit,  and  the  excitement  was,  if  any  thing,  greater  than  be- 
fore. Under  these  circumstances  it  was  thought  advisable  to  administer 
the  tartar  emetic  and  opium  in  the  manner  I  had  seen  it  exhibited, 
wliilst  acting  as  clinical  clerk  under  Doctor  Graves,  in  the  Meath  Hos- 
pital. He  got  an  ounce  of  a  mixture,  consisting  of  eight  ounces  of  cam- 
phor mixture,  four  grains  of  tartar  emetic,  and  a  drachm  of  laudanum 
every  second  hour,  and  after  he  had  taken  the  third  dose  he  had  a  large 
watery  evacuation ;  after  he  had  taken  the  fourth  dose  he  fell  into  a 
calm  sleep,  in  which  he  continued  for  nearly  twelve  hours ;  he  awoke 
much  refreshed  and  covered  with  a  profuse  perspiration.  He  was  able 
now  to  recognize  his  friends ;  the  subsultus  and  general  excitement  were 
greatly,  but  not  entirely  allayed;  his  pulse,  which  had  been  120  small 
and  wiry,  had  fallen  to  98 ;  he  continued  his  medicine  during  the  next 
night  with  the  greatest  benefit.  Prom  this  period  this  man^s  recovery 
was  rapid  and  unexpected,  and  at  the  end  of  three  weeks  he  was  able 
to  attend  to  his  business.^' 

The  next  case  was  reported  by  one  of  the  pupils  of  the  hospital. 
Ellen  Dowden,  aged  18,  admitted  into  the  Meath  Hospital  on  the  8th 
of  June,  states  that  she  has  been  ill  12  days.  Her  illness  commenced 
with  the  usual  symptoms ;  headache ;  rigor ;  loss  of  rest  and  appetite  : 
previously  to  her  admission  she  had  been  purged  freely  without  any 
relief.  On  the  day  of  her  admission  she  was  flushed ;  skin  dry  and  very 
hot ;  ths  whole  body  was  covered  with  maculae ;  she  was  heavy  and 
stupid;  answered  questions  incoherently;  her  eyes  were  slightly  suf- 
fused ;  she  called  out  continually  for  drink ;  her  tongue  was  dry,  brown, 
and  rough ;  seemed  to  have  much  pain  on  making  pressure  on  the  epi- 
gastrium ;  the  belly  was  swelled  and  tympanitic ;  bowels  confined ;  no 
cough  or  headache;  pulse  108,  wiry  :  eight  leeches  to  be  applied  to  the 
epigastrium ;  head  to  be  shaved  and  cold  lotion  applied. 

R  Hydrargyri  cum  Greta,  gr.  x.  ; 

Pulveris  Ipecacuanhse   compositi,  gr.   ii. 
Misce  ;  fiant  pulveres  quatuor,  in  die  sumendi. 

9th.  Much  worse  to  day ;  slept  for  about  one  hour  yesterday  even- 
ing ;  lies  continually  on  her  back  ;  seems  to  take  no  notice  of  what  is 
going  on  about  her ;  raved  occasionally  during  the  night ;  teeth  and 


220  CLINICAL   MEDICINE. 

mouth  covered  with  sordes ;  tongue  very  dry,  rough,  and  coated  with 
brown;  pulse  fallen  to  80,  very  small,  but  less  wiry  than  on  yesterday; 
epigastric  tenderness  much  relieved,  headache  gone,  maculae  less. 
To  have  a  pint  of  beer  and  arrow  root. 

R  Solutionis  Chloridi  Sodae,  min.  xv. ; 
Misturae  Oamphorae,  f  ^i. ; 
Guttse  nigrse,  min.  i.  ; 
Mi  see,  fiat  haustus  quater  in  die  sumendus. 

10th.  Raved  the  whole  night;  subsultus  general  and  violent;  pulse 
120,  sharp;  slightly  dicrotous;  slept  none;  face  much  more  flushed 
than  on  yesterday ;  eyes  suffused ;  passes  under  her ;  maculae  much  di- 
minished ;  has  no  headache ;  bowels  rather  free ;  Hes  on  her  back  with 
her  feet  drawn  up ;  has  no  chest  symptoms ;  respiration  natural ;  or- 
dered ice  in  bladders  to  the  head,  with  a  mixture  composed  as  fol- 
lows : — 

R  Misturae  Camphorae,  f  ^viii.  j 
Tartari  emetici,  gr.  i. ; 
Misce  sumat  f  ^ss.  omni  semihora. 

11th.  When  seen  yesterday  evening  she  was  very  violent;  en- 
deavoured to  get  out  of  bed ;  screamed  loudly,  and  complained  of  bad 
treatment ;  she  had  slept  none  at  this  period,  her  bowels  had  been  freed 
copiously,  but  she  still  continues  to  pass  under  her ;  she  endeavours  to 
throw  the  ice  bags  off  her  head,  and  requires  some  violence  to  hold  her 
in  bed ;  subsultus  extremely  violent ;  face  much  flushed ;  eyes  red ;  she 
was  ordered  the  following  : — 

Bs  Misturae  Camphorae,  f  ^viii. ; 
Tartari  emetici,  gr.  iv.  ; 
Tincturae  Opii,  f3  i. 
Misce,  sumat  f  ^ss.  secundis  horis. 

She  had  taken  but  two  tablespoonfuls  when  she  began  to  sleep ;  she 
has  continued  to  doze  to  the  hour  of  visit ;  she  is  much  improved  in 
every  respect;  she  answers  questions  rationally;  her  face  is  not  so 
much  flushed;  eyes  less  suffused;  has  no  headache;  pulse  120,  not  so 
sharp ;  skin  still  very  hot ;  tongue  moist  and  cleaning.  She  was  or- 
dered not  to  take  any  of  the  mixture  if  she  continues  better.  Enema 
emoUiens  statim.  Improvement  went  on  steadily  until  convalescence 
was  established. 

The  next  case  I  read  from  the  report  of  Dr.  Dwyer,  who  was  the 
physician  in  attendance : — "  In  compliance  with  your  request,  I  send 
you  an  abstract  of  the  case  of  Stephens.  It  was  one  of  spotted  fever 
occurring  in  a  young  man  of  temperate  habits,  setting  in  with  languor 
followed  by  rigor.  I  saw  him  on  the  4th  day,  when  there  was  un- 
pleasant heat  of  surface,  with  general  tenderness  aU  over  the  body,  par- 


TARTAR  EMETIC  AND  OPIUM  IN  FEVER.  221 

ticularly  remarkable  over  the  epigastric  region ;  the  chest,  arms  and 
hands,  studded  with  florid  maculae ;  headache  and  pain  of  back  dis- 
tressing; hght  disagreeable;  pulse   108;  tongue  moist.     He  had  an 
oil  draught,  followed  by  small  doses  of  hydrargyrum  cum  creta  with 
Dover's  powder.     On  the  6th  day  of  his  fever,  being  very  restless  and 
sleepless,  eyes  slightly  suffused,  and  pulse  120,  I  gave  him  an  eight 
ounce  mixture,  containing  four  grains  of  tartar  emetic,   and  a  drachm 
of  tincture  of  opium ;  two  table  spoonfuls  to  be  taken  in  the  evening, 
and  one  every  hour  afterwards.     On  the  next  day  the  report  was,  that 
he  had  slept  a  good  deal  during  the   night,   having  fallen  asleep  after 
the  third  dose,  tln-ee  hours  after  which  a  fourth  was  administered.     He 
is  dozing;  pulse  120  ;  skin  hot  and  dry;  bowels  four  times  moved; 
ordered  to  continue  his  mixture,  watching  its  effects.     On  the  8th  day, 
in  consequence  of  severe  purging  haviug  set  in,  (he  had  taken  but  two 
doses  of  the  mixture  since  last  report,)  the  epigastrium  becoming  very 
tender,  and  pulse  132,  his  medicine  was  omitted,  and  a  cretaceous  mix- 
ture ordered  instead,  a  small  quantity  of  port  wine  diluted,  and  a  blis- 
ter to  the  abdomen  ;  the  blister  was  not  applied,  yet  the  purging  was 
checked.     On  the  evening  of  the  9th  day,  as  he  complained  much  of 
want  of  rest,  and  there  was  no  headache,  I  directed  him  to  have  two  doses 
of  the  tartar  emetic  and  opium  mixture,  within  an  interval  of  two  hours. 
"  I  was  compelled  at  this  period  to  give  up  attendance  on  this  case 
in  consequence  of  an  accident ;  it  was,  however,  taken  up  by  Dr.  Grant, 
who  kindly  kept  notes,  and  with  whom  I  had  daily  conferences.      He 
reports  our  patient,  on  the  10  th  day,  to  have  suffered  an  accession  of 
fever,  seemingly  caused  by  abdominal  irritation  ;  he  complained  much  of 
headache ;  the  eyes  were  injected  ;  skin  hot  and  dry ;  tongue  brown  and 
crisp  ;  pulse  144 ;  respiration  49 ;  throbbing  of  the  temporal  arteries ; 
when  undisturbed,  raving  and  moaning,  but  answers  rationally ;  abdo- 
domen  fuU  and  tense,  tenderness  in  region  of  colon,  with  some  tenes- 
mus ;  sleeplessness.     He  was  given  four  grains  of  calomel  and  three  of 
extract  of  hyoscyamus,  followed  by  an  oil  draught ;  a  bhster  was  ap- 
plied to  the  abdomen  ;  cold  to  the  head,  and  warmth  to  the  feet.     The 
medicine  acted  well,  producing  a  number  of  dark-coloured  motions, 
with  some  relief  of  the  symptoms ;  the  sleeplessness,  however,  still  con- 
tinuing.    On  the  1 2th,  raved  considerably  the  previous  night,  with 
great  restlessness ;  headache,  with  darting  pain ;  pulse  120 ;  stiU  an- 
swers rationally,  but  raves  when  left  to  himself ;  abdomen  soft :  he  was 
again  put  on  the  use  of  the  tartar  emetic  and  opium  mixture,  to  have 
one  table  spoonful  every  hour  for  three  doses,  and  then  only  every  se- 
cond hour.     On  the  following  day  there  was  a  considerable  improve- 
ment ;  he  had  slept  well,  and  perspired  freely  in  the  night ;  no  raving  : 


222  CLINICAL   MEDICINE. 

headache  gone ;  pulse  96  ;  heat  of  skin  less ;  to  continue  his  mixture. 
On  the  14th  day  he  was  much  better ;  he  wished  for  food.  On  the 
15th  day  he  suffered  a  relapse,  from  liis  appetite  having  been  impru- 
dently indulged;  he  was  given  an  oil  draught,  and  directed  to  resume 
his  mixture  when  the  bowels  acted.  He  continued  from  this  time  to 
improve,  the  interval  between  the  doses  of  liis  mixture  was  gradually 
lengthened;  and  on  the  17th  day  he  was  convalescent. 

"  In  this  case  the  good  effects  of  this  mixture  were  evidenced  by 
perspiration  and  rest.  This  lad^s  mother  and  sister  were  just  conva- 
lescent from  spotted  fever ;  the  former  four  weeks,  the  latter  a  fort- 
night. In  the  mother's  case,  I  was  not  applied  to  tiU  the  10th  day; 
it  went  on  to  the  21st.  There  was  not  any  organ  particularly  impli- 
cated; she  was  treated  with  stimulants,  carbonate  of  ammonia,  porter,  and 
blisters.  In  the  daughter,  the  fever  was  very  severe  to  the  1 1th  day, 
when  it  terminated  by  profuse  perspiration.  She  suffered  principally 
from  pain  in  her  head  and  back,  with  intolerance  of  light,  and  was 
treated  with  mild  aperients,  followed  by  diaphoretics  with  hyoscyamus. 
In  neither  was  sleeplessness  distressingly  remarkable.  Another  brother 
was  seized  with  the  same  form  of  fever  a  few  days  after  the  subject  of 
this  case  had  taken  iU ;  he  was  on  the  5th  day  transferred  to  Sir  Patrick 
Dun's  Hospital. 

"  I  experienced  marked  benefit  from  tliis  form  of  prescription  in  a 
case  of  melancholia,  occurring  in  a  female  aged  45,  consequent  on  a 
severe  domestic  affliction.  The  exhibition  of  it  here,  however,  was 
followed  by  considerable  debility,  requiring  stimulants.  This  effect  I 
consider  to  have  been,  in  some  degree  at  least,  attributable  to  the 
patient  having  for  some  days  previous  to  its  exhibition  refused  food,  and 
possibly  been  suffered  to  remain  too  long  under  the  sedative  influence 
of  this  medicine  without  having  been  offered  nourishment.'' 

The  following  is  also  an  interesting  example  of  the  efficacy  of  this 
plan  of  treatment : — 

John  DiUon,  aged  15,  a  servant,  admitted  into  Hospital  5th  June, 
1835,  several  days  iU.  On  the  day  of  his  admission  he  had  headache, 
thirst,  heat  of  skin,  loss  of  appetite  and  rest ;  his  face  was  flushed  and 
bloated;  eyes  suffused,  red  and  prominent;  skin  hot  and  dry.  He 
complained  of  slight  epigastric  tenderness  and  violent  headache ;  pulse 
120,  fall  and  bounding.  His  whole  body  was  covered  with  maculae ; 
bowels  regular ;  tongue  brown,  furred,  and  dry.     Ordered 

R     Aquae,  f.gi. 

Liquoris  Chloridi  Sodae,  min.  x. 
Misce,  fiat  haustus  quartis  horis  sumendus. 

Applicentur  hirudines  xii.  post  aurem,  et  repetatur  applicatio  si 
opus  sit. 


TARTAE   EMETIC    AND    OPIUM    IN    FEVER.  223 

7  th.  The  leeches  bled  freely ;  head  appears  to  be  relieved  ;  he 
raved  a  good  deal  during  the  night ;  his  pulse  has  fallen  to  100,  but 
still  very  full ;  has  a  slight  cough,  and  some  bronchitis.  Ordered  to 
repeat  the  draught,  and  apply  four  leeches  to  the  larynx. 

8th.  Slept  very  little ;  does  not  appear  improved ;  very  irritable ; 
raved,  and  was  rather  violent  during  the  night ;  cough  better ;  tongue 
very  brown  and  dry;  bowels  confined;  pulse  100 ;  respirations  rather 
hurried.  Ordered  to  repeat  the  draught,  and  to  have  an  emollient 
enema  in  the  evening. 

9th.  Epigastric  tenderness  much  increased ;  raved  continually  dur- 
ing the  night ;  slight  subsultus  ;  eyes  very  red,  wild  and  staring ;  pulse 
114,  very  full;  tongue  dry  and  brown;  teeth  covered  with  sordes.  To 
repeat  the  draughts,  and  apply  eight  leeches  to  the  epigastrium. 

10th.  Appears  better  to-day;  epigastric  tenderness  much  relieved 
by  the  leeching;  his  strength  is  much  prostrated;  wishes  for  more 
food;  pulse  100,  and  still  full ;  slept  none.  Ordered  arrowroot,  and 
to  repeat  the  draughts. 

11th.  The  fever  is  again  much  increased;  raved  violently  during 
the  night  ;  great  prostration  ;  slept  none  ;  subsultus  very  violent ; 
great  thirst ;  pulse  130  ;  complains  of  a  heaviness,  but  no  pain  in 
head;  skin  very  hot  and  dry;  eruption  undiminished.  Ordered  to 
repeat  as  before. 

12th.  AH  the  symptoms  much  aggravated ;  face  flushed  and  red ; 
eyes  suffused  and  ferrety ;  teeth  covered  with  sordes ;  Hps  parched  and 
cracked ;  tongue  black  and  very  dry ;  subsultus  general  and  violent ; 
does  not  sleep  either  by  night  or  day;  exceedingly  irritable;  pulse  130 
and  jerking ;  pupils  contracted ;  he  lies  on  his  back  with  legs  drawn 
up ;  extremities  rather  cold.  He  was  ordered  warm  applications  to  his 
feet  and  the  following  prescription : — 

R     Tartari  emetici,  gr.ii. 

Misturse  Camphorse,  f^viii. 

Tincturse  Opii,  f9ii. 

Misce,  sumat  cochleare  unum  amplum  secunda  quaque  hora. 

13th.  The  nurse  reported  that  after  he  had  taken  the  mixture  three 
times,  he  slept  calmly  for  nine  or  ten  hours  the  first  time  for  the  last 
week.  It  operated  largely  after  the  second  dose,  the  stools  being  thin 
and  bilious.  He  has  ceased  to  rave ;  the  suffusion  has  quite  disap- 
peared ;  tongue  is  moist  and  cleaning.  He  slumbers  continually ;  sub- 
sultus completely  subdued ;  answers  questions  rationally ;  pulse  has 
fallen  to  98  and  soft;  ordered  to  repeat  the  mixture. 

14th.  Slept  continually  since  last  report;  general  appearance  much 
improved ;    perspired  profusely   during  the  night.     He  was  perfectly 


224  CLINICAL  MEDICINE. 

sensible  from  this  day  till  the  17th.  He  continued  to  improve  rapidly 
in  strength  and  appearance. 

17th.     Convalescent. 

And  with  one  more  case  I  shall  conclude  for  to  day.     Mr.  S , 

residing  in  College,  was  attacked  with  headache,  on  the  3rd  February, 
1836,  and  fever  commenced  on  that  or  the  following  day.  He  was 
judiciously  treated  by  Mr.  Barker,  of  Britain-street,  until  the  fourth 
day  of  the  fever,  when  an  increase  of  headache  and  pain  in  or  behind 
the  ball  of  the  right  eye,  induced  him  to  call  me  in.  A  bleeding  from 
the  arm  much  relieved  the  pain,  and  he  spent  a  tranquil  night.  He 
got  calomel  and  Jameses  powder  in  small  doses.  On  the  5th  no  change. 
Sixth  day  of  fever,  maculae  began  to  appear,  and  his  state  became  more 
alarming.  Seventh  day,  maculae  abundant,  restlessness,  debility,  very 
frequent  sighing,  thirst,  &c.,  with  a  sharp  pulse,  and  return  of  head- 
ache. Leeches  to  head  and  nostrils  were  ordered ;  the  latter  because 
of  an  evident  tendency  to  epistaxis.  8th.  Sir  Henry  Marsh  saw  him 
along  with  us.  9th  and  10th.  Grain  doses  of  Dover's  powder  added 
to  his  medicine  four  times  in  the  night,  but  did  not  procure  rest. 

11th.  Perfectly  sleepless  night  and  day;  ordered  in  the  evening,  one 
grain  of  tartar  emetic,  four  ounces  of  camphor  mixture,  and  one 
scruple  of  laudanum;  one  table-spoonful  every  second  hour.  12th. 
Moisture  on  skin ;  began  to  sleep  after  second  dose,  and  slept  several 
hours  tranquilly ;  is  to-day  quite  free  from  muttering  and  raving,  which 
had  commenced  on  the  10  th  day,  and  increased  on  the  11th;  so  that 
when  left  to  himself  he  lay  on  his  back  constantly  speaking,  but  not  in 
a  loud  or  boisterous  manner,  his  eyes  being  aU  the  time  open ;  when 
addressed  he  answered  quite  rationally,  but  on  our  quitting  the  room 
began  again  immediately  to  ramble.  This  group  of  unpleasant  symp- 
toms having  disappeared,  we  did  not  continue  the  medicine,  but  ordered 
palKatives  and  mild  nourishment ;  in  the  evening  it  was  judged  right 
to  apply  a  blister  to  the  nape  of  the  neck.  13th  day,  maculae  very 
abundant ;  was  quiet  during  the  night,  but  did  not  sleep  at  aU ;  ex- 
hausted and  nervous ;  other  symptoms  moderate;  pulse  104;  tongue 
moist ;  abdomen  a  httle  swoUen  and  slightly  tympanitic ;  turpentine 
injections;  palliative  diuretic  draughts;  chicken  broth:  claret  and 
water.  At  five  p.  m.  I  again  saw  liim,  and  found  him  still  quite  sleep- 
less, but  without  headache ;  bowels  moved,  but  still  shghtly  tympanitic. 
Fearing  the  continued  exhaustion  from  want  of  rest,  I  now  ordered  a 
mixture  consisting  of  one  ounce  of  mucilage  of  gum  arabic,  seven 
ounces  of  camphor  mixture,  tliree  grains  of  tartar  emetic,  and  one 
drachm  by  measure  of  laudanum ;  half  an  ounce  every  second  hour, 
until  sleep  comes  on. 


TARTAR   EMETIC    AND    OPIUM    IN    FEVER.  225 

At  ten,  Sir  Henry  Marsh  and  Mr.  Barker  saw  him ;  he  had  slept  an 
hour ;  appeared  drov/sy,  and  did  not  complain  of  headache  ;  two  doses 
of  the  medicine  had  been  given ;  he  remained  awake  until  eleven,  when 
another  dose  caused  him  to  sleep  until  three ;  at  four  another  was  given, 
after  which  he  slept  until  eight,  and  awoke  much  refreshed,  and  much 
improved  in  every  respect ;  his  belly  had  not  been  moved,  and  was 
still  sHghtly  tympanitic,  a  symptom  which  yielded  to  the  administration 
of  two  drachms  of  castor  oil  exhibited  in  the  form  of  an  aromatic 
emulsion.  In  the  evening  he  was  ordered  to  take  four  drops  of  black 
drop,  but  this  procured  no  sleep  during  the  night.  On  the  morning  of 
the  15th  day  we  found  him  somewhat  exhausted  from  a  sleepless  night, 
but  with  much  less  fever  and  no  headache  :  pulse  94,  soft ;  for  the 
first  time  we  remarked  subsultus  :  a  family  idiosyncrasy,  rendering  musk 
pecuHarly  disagreeable,  or  even  intolerable,  we  ordered  a  draught  con- 
taining two  drops  of  black  drop,  and  fifteen  of  Hoffmanns  liquor,  every 
fourth  hour.  In  the  evening  he  had  slept  very  little,  so  that  I  resolved 
again  to  recur  to  the  antimonial  opiate ;  two  spoonfuls  of  which  pro- 
duced sound  refreshing  sleep  for  several  hours.  In  the  morning  he 
again  got  castor  oil;  and  on  this,  the  16th  day,  his  pulse  was  only  70; 
but  stiU,  though  the  subsultus  was  diminished,  a  remnant  of  it  could 
be  perceived,  so  that  he  could  not  be  pronounced  out  of  all  danger. 

The  conclusion  of  this  case  is  peculiarly  instructive,  and  proves  how 
insidious  is  the  progress  of  fever,  and  how  unsafe  the  condition  of  a 
patient,  whose  brain  and  nervous  system  have  received  a  violent  shock, 
even  although  the  immediate  consequences  of  that  shock  have  been 
averted  by  the  employment  of  decided  treatment.  On  the  16th  day 
we  have  seen  an  abatement,  or  rather  a  disappearance  of  almost  every 
symptom  of  the  disease,  save  and  except  a  slight,  a  scarcely  perceptible 
remnant,  of  the  subsultus.  Great  care  was  taken  to  prevent  his  being 
disturbed,  and  the  strictest  attention  as  to  diet  was  enjoined ;  indeed  he 
was  remarkably  disinclined  to  taking  food,  and  it  was  with  great  diffi- 
culty that  we  could  get  him  to  consume  a  sufficient  quantity  of  mild 
farinaceous  diet.  On  the  night  of  the  16th  day  he  slept  tolerably. 
The  1 7th  day  was  passed  without  any  change ;  but  he  slept  none  that 
night. 

The  18th  day  he  was  perfectly  free  from  fever;  pulse  70  ;  tongue 
moist ;  bowels  opened  by  medicine.  That  day  he  conversed  too  much 
to  his  friends  about  his  removal  to  the  country,  his  future  plans,  &c.  ; 
but  nevertheless  he  slept  several  hours  towards  evening.  This  sleep 
was  disturbed  "and  chequered  by  dreams,  and  on  awaking  aboui  eleven 
o'clock,  he  was  wandering,  and  got  eight  drops  of  black  drop,  which 
procured  no  rest ;  on  the  contrary  he  got  several  times  out  of  bed,  and 

VOL.  I.  15 


226  CLINICAL    MEDICINE. 

spoke  incoherently.  The  raving  had  all  subsided  at  10  a.  m.  on  the 
19th  day,  when  I  was  in  hopes  it  was  entirely  owing  to  temporary  ex- 
citement, and  would  not  return ;  an  opinion  rendered  probable  by  a 
total  absence  of  all  symptoms  of  general  or  local  vascular  excitement, 
of  headache,  &c.  In  this  expectation,  however,  I  was  disappointed, 
for  early  in  the  afternoon  he  became  incoherent ;  raved  more  and  more 
every  hour ;  complained  of  headache ;  could  not  bear  the  light ;  and 
when  I  saw  him  at  seven,  he  was  quite  irrational ;  supposed  himself  to 
be  travelling ;  and  when  questioned  he  seemed  not  to  understand  ;  his 
pulse  had  fallen  below  60 ;  was  soft,  irregular,  and  intermitted  very 
frequently ;  skin  not  hot ;  feet  cold ;  features  contracted  j  tip  of  nose 
cold ;  he  had  eaten  stirabout  in  small  quantity  twice  during  the  day, 
but  in  a  voracious  unnatural  manner ;  his  eyes  were  a  little  red,  and 
every  thing  wore  a  most  threatening  aspect. 

What  was  now  to  be  done  ?  In  directing  his  head  to  be  shaved 
anew,  and  in  applying  blisters  to  his  scalp  and  temples,  I  felt  I  was 
proceeding  on  sure  grounds ;  but  the  indications  for  the  internal  treat- 
ment were  less  obvious.  We  had  arrived  at  the  19th  day,  and  he  had 
gone  through  a  debilitating  fever,  and  had  been  submitted  to  a  very 
active  mode  of  treatment.  Were  we  to  leech  the  head  ?  were  we  to 
apply  cold  ?  and  should  we  immediately  endeavour  to  mercurialize  the 
system  by  means  of  mercurial  preparations,  given  internally  and  applied 
externally  ?  Such  would  have  been  the  treatment  a  patient,  under 
similar  circumstances,  would  have  undergone  at  the  hands  of  any  prac- 
titioner a  very  few  years  ago ;  and  I  have  no  doubt  that  a  treatment 
of  this  nature  would  have  speedily  brought  matters  to  a  fatal  termina- 
tion. 

The  writings  of  Gooch,  however,  who  pointed  out  the  diagnosis  and 
treatment  of  certain  cases,  usually  confounded  with  inflammatory  hydro- 
cephalus, and  the  influence  of  the  truth  of  Dr.  Gooch's  statement,  as 
illustrated  by  several  examples  in  our  own  practice,  determined  Sir 
Henry  Marsh,  Mr.  Barker,  and  myself,  to  rely  on  the  severe  blistering 
locally,  while  internally,  we  ordered  a  draught  consisting  of  two  grains 
of  carbonate  of  ammonia,  twenty  drops  of  HofTman^'s  liquor,  and  one 
ounce  of  camphor  mixture,  to  be  taken  every  third  hour.  Warmth  was 
applied  to  the  feet,  and  he  was  supplied  with  warm  whey.  Shortly  after 
our  visit  he  fell  asleep,  slept  with  little  interruption  for  about  seven 
hours,  and  awoke  perfectly  rational ;  and  at  eight  o^ clock  next  morning, 
being  the  20th  day,  we  found  him  much  better  in  every  respect ;  the 
only  vestige  of  this  alarming  attack  that  remained  being  some  intermis- 
sion in  the  pulse,  which  had  become  in  other  respects  much  more 
natural  and  fuller.     The  bowels  had  not  been  opened ;  a  circumstance 


TARTAR  EMETIC  AND  OPIUM  IN  FEVER.  227 

I  mention  because,  no  doubt,  some  would  have  ordered  purgatives  on 
such  an  emergency,  a  practice  which  the  fallen,  soft  state  of  the  belly 
did  not  seem  to  us  to  call  for,  and  which  our  view  of  the  nature  of  the 
case  prevented  us  from  proposing.  We  ordered  farinaceous  diet,  and  a 
repetition  of  the  draughts,  at  longer  intervals.  In  the  evening  of  tlie 
21st  day  the  pulse  had  lost  all  remnant  of  irregularity  or  intermission, 
and  the  disturbance  of  the  nervous  system  had  entirely  subsided  :  from 
that  period  his  convalescence  commenced. 

One  fact  connected  with  the  cases  just  related  is  very  striking,  viz., 
the  small  quantity  of  laudanum  which,  in  most  of  them,  was  sufficient 
to  induce  sleep ;  a  cu'cumstance  only  to  be  accounted  for  by  the  pre- 
sence of  the  tartar  emetic,  which  no  doubt  exerts,  when  given  in  duly 
regulated  doses,  a  powerfully  tranquillizing  effect  on  the  nervous  system. 
It  is  also  deserving  of  remark,  that  the  combination  very  seldom  gives  rise 
to  any  of  the  unpleasant  symptoms  that  so  frequently  arise  when  opium 
alone,  or  any  of  its  preparations,  are  given  with  a  view  of  producing 
sleep  at  an  advanced  period  of  fever.  The  addition  of  one  ounce  of 
mucilage,  and  one  ounce  of  simple  syrup  to  the  mixture,  seems  to 
render  it  less  likely  to  disagree  with  the  stomach.  Towards  the  termi- 
nation of  fever,  it  not  unfrequently  happens  that  a  sudden  or  gradual 
determination  of  blood  to  the  head  arises,  and  which  requires  a  repeti- 
tion of  a  modified  system  of  antiphlogistic  treatment,  aided  by  blisters. 
This  state,  I  have  reason  to  believe,  may  be  often  prevented  from  oc- 
curring, by  a  timely  attention  to  procuring  sleep ;  for  a  patient  in  fever, 
who  has  passed  several  sleepless  nights,  is  on  the  verge  of  cerebral  con- 
gestion or  inflammation,  as  is  testified  by  headache,  wandering,  and  the 
redness  of  the  conjunctiva.  Here  it  is  that  the  treatment  I  recommend 
is  so  advantageous,  when  timely  applied;  for  if  it  be  deferred  until 
cerebral  inflammation  has  set  in,  opium  in  any  shape  is  worse  than 
useless. 

The  particular  state  of  the  nervous  system  to  which  this  combination 
of  remedies  is  best  adapted,  may  occur,  along  with  other  symptoms  pro- 
duced by  functional  or  organic  lesions  of  various  organs,  and  which 
prevent  it  from  producing  the  wished  for  beneficial  result.  Thus  when 
the  beUy  is  tense  and  swollen,  this  remedy  will  generally  fail ;  but  I 
think  that  I  am  warranted  in  asserting  that  in  fevers,  properly  treated 
from  the  first,  tympanitis  may  commence,  but  will  never  become  consi- 
derable ;  for,  if  the  attention  of  the  practitioner  be  applied  to  this 
symptom  the  moment  it  begins  to  show  itself,  he  can  in  most  cases 
succeed  in  arresting  its  progress.  I  have  hkewise  seen  several  xBases  of 
fever,  where  I  expected  benefit  from  the  tartar  emetic  and  opium,  and 

!       in  which  no  srood  result  followed  the  exhibition  of  these  medicines; 

\ 
1 


228  CLINICAL  MEDICINE. 

such  failures  must  always  occur  with  respect  to  every  remedy  we  apply 
in  disease,  but  they  do  not  invalidate  the  oj^idence  of  facts,  such  as  I 
have  brought  forward  in  proof  of  their  frequent  utility. 

In  connexion  with  this  subject,  I  beg  leave  to  draw  your  attention  to  the 
occurrence  of  delirium  traumaticum  in  fevers,  in  consequence  of  the  irri- 
tation produced  by  bhsters,  a  species  of  dehrium  apt  to  be  mistaken, 
especially  in  cliildren,  for  the  delirium  ushering  in  hydrocephalus.  I 
shall  not  do  more  now  than  advert  to  this  subject. 

Before  concluding  it  is  right  to  remark,  that  the  relative  proportions 
of  tartar  emetic  and  laudanum  in  the  mixture  must  be  varied  according 
to  circumstances.  When  congestion  of  the  brain  is  known  to  exist,  or 
is  feared,  the  tartar  emetic  must  not  faU.  short  of  four  grains  in  the 
eight  ounces,  while  the  laudanum  should  not  exceed  half  a  drachm ;  but 
where  nervous  symptoms  predominate,  the  laudanum  may  amount  to 
one  drachm,  and  the  tartar  emetic  to  two  grains  :  no  general  rule,  how- 
ever, can  be  laid  down,  and  the  practitioner  must  in  all  cases  watch  the 
effects  of  this  medicine ,  from  hour  to  hour,  until  he  ascertain  whether  it 
agrees  with  the  patient  or  not.  Where  a  life  is  at  stake,  we  must  spare 
no  pains,  and  must  not  reject  a  remedy  because  its  powers  render  it  an 
instrument  of  good  or  evil,  according  as  it  is  administered  carefully  or 
otherwise. 


229 


LECTURE  XVIII. 

MACULATED  FEVER. ^TARTAR  EMETIC  IN  LARGE  DOSES  IN  THE  ADVANCED 

STAGES  OP  MALIGNANT  FEVER. 

When  I  last  addressed  you,  I  spoke  of  a  very  important  topic — ^the  ad- 
ministration of  tartar  emetic  and  opium,  in  the  advanced  stages  of  spotted 
or  maculated  fever.  A  few  observations  descriptive  of  the  present  epidemic 
fever,^  appear  necessary.  The  commencement  is  frequently  by  no  means 
violent,  in  proportion  to  the  subsequent  danger,  and  the  patient  often 
appears  merely  to  labour  under  the  symptoms  of  a  common  feverish 
cold,  seldom  preceded  by  violent  rigors,  but  attended  by  a  frequently 
recurring  sense  of  horripilation.  The  pulse  in  the  very  beginning, 
seldom  exceeds  90,  and  in  nearly  half  the  cases  it  falls  after  a  few  days 
to  80,  70,  or  even  lower.  This  slow  pulse  I  observed  in  many  of  the 
pupils,  and  in  all  it  was  found  to  accompany  a  very  tedious  and  dan- 
gerous form  of  fever.  Mr.  Sangster,  Mr.  Graves,  Mr.  Harris,  and  Mr. 
OTlaherty,  were  all  so  affected;  for  none  of  these  gentlemen  had  a 
pulse  exceeding  70  in  a  minute,  for  many  days  before  the  period  of  the 
greatest  danger.  In  other  epidemics  similar  cases  have  occasionally  oc- 
curred, but  in  none  near  so  frequently  as  in  the  present.  When  the 
pulse  was  thus  tranquil,  the  skin  was  not  perceptibly  hotter  than  natural, 
although  occasionally  a  shght  degree  of  the  calor  mordax  could  be 
detected. 

Patients  with  a  slow  pulse  not  unfrequently  had  little  to  complain 
of  at  first ;  for  the  headache,  general  pains,  thirst,  and  restlessness,  ge- 
nerally underwent  a  notable  diminution,  in  consequence  of  sweating 
which  came  on  in  the  commencement — the  appearance  and  the  good 
effects  of  which  were  well  calculated  to  deceive  the  practitioner  into  a 
belief  that  the  fever  had  terminated.  A  more  accurate  examination, 
however,  showed  that  this  was  not  the  case ;  for  the  tongue  still  con- 
tinued much  loaded,  white  in  the  centre  and  red  at  the  tip,  and  the  ap- 
parent subsidence  of  the  fever  was  found  to  be  accompanied  by  a  re^ 

*  1834-35. 


230  CLINICAL   MEDICINE. 

markable  increase  of  debility.  As  the  disorder  proceeded^  a  slight  rash,, 
like  ill-defined  or  suppressed  measles,  became  observable  in  some  before 
the  fourth  day,  but  much  oftener  about  the  seventh.  This  maculated 
appearance  of  the  skin  increased  rapidly,  spreading  over  all  parts  of  the 
trunk  and  extremities,  and  in  many  amounted  to  a  well-marked  eiflores- 
cence  of  a  dusky  red  colour  ;  in  others  it  was  as  it  were  suppressed,  and 
was  less  obvious,  but  was  still  discernible  by  an  experienced  eye,  appear- 
ing beneath  as  if  veiled  by  the  skin.  It  was  not  totally  absent  in  one 
case  out  of  twenty,  which  induced  me  to  name  the  disease  maculated 
fever. 

So  the  patient  continued,  in  general,  until  the  ninth,  tenth,  or  eleventh 
day,  resting  sufficiently  at  night,  with  a  moderate  or  even  a  slow  pulse, 
some  thirst,  foul  tongue,  little  or  no  nausea,  epigastric  pain,  or  abdomi- 
nal tenderness  of  any  sort,  and,  in  fact,  without  a  single  symptom  calcu- 
lated to  excite  alarm.  About  this  period  of  the  complaint  matters  began 
to  assume  a  more  threatening  aspect ;  debility  manifestly  increased ;  the 
mind  at  times  was  evidently  incoherent,  particularly  after  awaking  from 
sleep,  and  then  raving  during  the  night ;  restlessness ;  frequent  at- 
tempts to  get  out  of  bed  very  generally  supervened  in  the  course  of  a 
few  days.  The  pulse,  meantime,  rose  very  suddenly  in  many,  and  con- 
tinued to  be  frequent  during  the  period  of  danger.  Thus,  on  the  tenth 
day,  Mr.  Syms's  pulse  rose  from  85  to  120,  and  so  continued  until 
about  the  twentieth  day,  when  improvement  commenced.  The  same 
sudden  rising  of  the  pulse  took  place  on  the  ninth  day  in  Mr.  M'Namara, 
and  he  died  on  the  fourteenth  day.  In  others,  as  I  have  already  re- 
marked, the  pulse  continued  tranquil  throughout. 

Thus,  it  was  very  curious  to  see  a  patient  with  a  skin  of  a  natnral 
temperature^  a  perfectly  natural  pulse,  tranquil  respiration,  clear  eye, 
no  headache,  a  soft  and  fallen  abdomen,  without  the  slightest  tende^icy 
to  epigastric  tenderness :  it  was  very  curious,  I  say,  to  see  such  a  patient 
in  a  state,  nevertheless,  of  extreme  danger,  passing  both  £eeces  and  urine 
under  him  ;  raving,  incoherent,  or  with  a  low  muttering  delirium ;  sub- 
sultus  daily  increasing  until  it  became  excessive ;  the  greatest  possible 
degree  of  debihty ;  a  dark  macular  efflorescence,  and  at  length  total 
sleeplessness.  How  many  theories  of  fever  were  refuted  by  such  a  case  ! 
Usually,  as  the  disease  continued,  and  when  the  patient  was  in  a  very 
dangerous  state — but  seldom  or  never  before  that — the  intestines  began 
to  be  inflated,  and  the  belly  gradually  became  tympanitic ;  a  circum- 
stance of  bad  omen,  and  which  was  often  the  precursor  of  hiccup. 

When  the  symptoms  did  not  yield  to  the  efforts  of  nature  or  art,  the 
congestion  of  the  intestinal  mucous  membrane,  indicated  by  these 
symptoms,  was  soon  followed  by  indubitable  evidence   of  cerebral  con- 


MACULATED    FEVP:E.  231 

gcstlou — such  as  restlessness,  suffusion  of  tlie  adnata,  and  contraction 
of  the  pupils ;  this  last  was  the  most  fatal  of  all  symptoms.  In  two  or 
three  cases — as,  for  instance,  that  of  Mr.  Cookson — the  cerebral  con- 
gestion produced  repeated  fits  of  convulsions  on  the  thirteenth  day,  and 
yet  he  recovered.  The  same  happened  in  a  young  woman  in  Sir  P. 
Dun's  Hospital,  in  whom  the  convulsions  occurred  on  the  fifteenth  day, 
and  were  more  violent  on  the  right  side  than  on  the-  left,  producing 
strabismus  and  insensibility  of  the  pupil  of  the  affected  eye.  This  girl 
lost  the  use  of  her  left  side  on  that  day,  but  recovered  it  on  the  follow- 
ing; and  eventually,  though  with  difficulty,  was  completely  cured. 
Frequent  fits  of  convulsions,  affecting  the  right  side  more  than  the  left, 
took  place  on  the  seventh  day  in  the  daughter  of  a  clergyman  residing 
in  the  Liberty,  and  were  followed  by  a  stupor  bordering  on  coma,  which 
lasted  for  many  hours.  All  these  patients  were  covered  with  ma- 
cula3. 

There  is  one  circumstance  connected  with  this  epidemic,  which  I 
liave  also  frequently  witnessed  in  other  sporadic  and  epidemic  fevers,  to 
which  I  wish  forcibly  to  draw  your  attention ;  it  is  the  existence  of  teii- 
derness  generally  over  the  body ;  and  which  causes  the  patient  to  shrink 
from  the  pressure  of  the  finger,  applied  to  any  part  of  the  integuments. 
This  tenderness  arises  from  an  irritated  state  of  the  nervous  system  ge- 
nerally, and  is  usually  accompanied  by  severe  dorsal  or  lumber  pain,  in- 
dicating spinal  congestion.  Now,  in  a  practical  point  of  view,  this 
tenderness  requires  attention ;  for  if  it  be  overlooked,  and  if  the  physi- 
cian applies  pressure,  in  such  cases,  only  to  the  epigastrium,  he  will  be 
deceived  into  the  belief  that  the  tenderness  he  there  discovers  is  con- 
fined to  that  part,  and  indicates  the  application  of  leeches  to  the  pit  of 
the  stomach. 

I  am  thus  particular  in  dwelling  on  the  symptoms  manifestly  denot- 
ing a  combination  of  primary  general  nervous  excitement  with  a  second- 
ary cerebral  congestion ;  for,  on  the  successive  development  of  these 
states  the  treatment  during  the  latter  stages  hinged.  I  wish  you  clearly 
to  understand,  that,  after  the  headache  and  cerebral  excitement  which 
accompanied  the  very  commencement  of  the  fever  had  hpen  subdued, 
or  had  ceased,  after  sleep  and  calm  had  returned,  and  had  continued  for 
many  days,  then  a  new  order  of  things  commenced — subsultus,  watch- 
fulness, muttering,  raving,  involuntary  discharges,  &c. — all  denoting 
great  derangement  of  the  nervous  system  ;  but  still  there  was  no  proof 
that  this  derangement  depended  on  cerebral  congestion. 

After  a  few,  or  after  many  days,  however,  unequivocal  symptoms  of 
the  latter  set  in ;  the  face  and  eyes  became  suffused  and  flushed ;  the 
pupils  manifested  a  tendency  to  become  contracted^  and  occasionally 


232  CLINICAL   MEDICINE. 

convulsions  took  place ;  the  patient  became  also  totally  sleepless.  A\  lien 
the  latter  and  dangerous  period  of  the  fever  was  accompanied  by  the 
the  former  nervous  group  of  symptoms  alone^  they  yielded  to  wine, 
musk,  porter,  and  opiates ;  but  when  the  symptoms  indicating  cerebral 
congestion  were  superadded,  then  it  was  that  the  case  assumed  so  great 
and  striking  a  similarity,  so  far  as  the  functions  of  the  nervous  system 
were  concerned,  to  the  well-known  variety  of  delirium  tremens,  accom- 
panied by  cerebral  congestion,  to  which  I  before  referred — to  that  va- 
riety of  dehrium  tremens,  in  fact,  which  only  can  be  successfully  treated 
by  the  judicious  but  bold  exhibition  of  tartar  emetic  combined  with 
laudanum.  It  is  the  discovery  of  the  utility  of  this  practice  in  the  ad- 
vanced stages  of  spotted  fevers  j  that  I  claim  peculiarly  as  my  own  ;  for 
there  is  not  in  the  writings  of  any  author  on  the  subject,  the  slightest 
trace  of  such  a  method  of  treatment  to  be  found.  As  this  method  has 
manifestly  saved  many,  many  lives,  under  a  combination  of  circumstances 
apparently  hopeless,  I  cannot  avoid  congratulating  myself  upon  being 
the  first  to  propose  a  practice  which  has  not  only  diminished  the  rate  of 
our  hospital  mortality"^  in  a  remarkable  manner,  but  has  been  the  means 
of  saving  many  of  my  friends  and  pupils ;  for,  without  its  adoption, 
our  class  at  the  Meath  Hospital  would  have  been  more  than  decimated, 
whereas  at  present  we  have  to  regret  the  loss  of  but  one  pupil. 

One  word  more  as  to  the  circumstances  under  which  this  plan  was 
applicable.  They  were  exactly  the  circumstances  which  formerly  would 
have  been  believed  to  demand  the  fresh  application  of  leeches  to  the 
head,  of  cold  lotions,  and  of  blisters ;  for  it  was  formerly  argued,  and 
justly,  we  have  in  this  advanced  stage  of  fever  not  merely  debility  to 
combat — not  merely  general  nervous  excitement  to  overcome — but  we 
have  also  to  contend  with  cerebral  congestion.  The  latter  is  the  most 
formidable  of  the  whole  :  it  was,  therefore,  said,  let  us  meet  it  boldly ; 
let  us  leech,  let  us  purge,  &c. ;  but  I  need  not  repeat  to  you  the  details 
of  cases  illustrating  the  ill  effects  of  this  practice.  Suffice  it  to  remark, 
that  you  might  as  well  attempt  to  cure  delirium  trefnens  with  mere  leech- 
ing, purging,  and  bhstering.  Observe,  I  am  now  speaking  of  the  ad- 
vanced stages  of  fever ;  for  where  cerebral  congestion  takes  place  in  the 
beginning  or  the  middle  of  fever,  then  there  is  no  room  for  opium — 
then  will  the  practitioner  have  recourse  to  the  well-known  remedies  for 
active  cerebral  congestion ;  viz.,  purging,  leeches,  cold  lotions,  ice   to 

*  Seventy-three  fever  patients — namely,  forty-one  males  and  thirty-two  females,  were 
treated  in  the  clinical  wards  at  Sir  P.  Dun's  Hospital  during  the  months  of  February, 
March,  and  April.  Of  these  more  than  fifty  were  cases  of  maculated  or  spotted  fever, 
and  yet  we  lost  but  two  females  and  one  male.  The  latter  was  in  a  hopeless  condition 
when  brought  in,  and  one  of  the  former  was  attacked  by  varioloid  just  after  the  crisis  of 
long  continued  spotted  fever. 


I 


TARTAR    EMETIC    AND    OPIUM    IN    FEVER.  233 

tlie  head,  &c.  In  the  preceding  sketch  of  the  present  epidemic,  many 
important  features  have  been  omitted.  The  outline  is  only  complete  in 
such  parts  as  were  required  to  be  filled  up  for  the  purpose  of  illustrating 
the  principles  which  directed  me  in  devising  and  employing  this  new 
plan  of  treatment.  I  cannot  better  illustrate  these  principles  and  their 
results  for  you  than  by  the  details  of  some  additional  cases,  and  first 
let  me  call  your  attention  to  that  of  Mr.  Thomas  OTlaherty. 

This  young  gentleman  was  seized  with  the  usual  symptoms  of  macu- 
lated fever,  of  an  insidious  character,  and  not  attended  with  any  appear- 
ance of  danger  during  the  commencement  of  the  disease.  His  pulse 
never  rose  above  100,  and  before  the  seventeenth  day  of  the  fever,  it 
had  fallen  to  70,  at  which  it  remained  during  the  period  of  greatest 
danger.  The  only  circumstance  which  excited  alarm  in  my  mind,  at 
an  early  period  of  his  illness,  was  a  great  degree  of  mental  appre- 
hension manifested  in  his  anticipating  an  unfavourable  result,  together 
with  a  tendency  to  sleeplessness  from  the  beginning.  On  the  tenth, 
abdominal  tympanitis  was  observed,  but  this  was  removed  in  two  days 
by  appropriate  remedies.  On  the  twelfth  day  he  was  very  restless,  and 
although  he  was  perfectly  rational  in  liis  answers  to  questions,  and  did 
not  complain  of  headache,  had  neither  flusliing  of  face,  nor  heat  of  the 
integuments  of  the  head,  yet  he  frequently  talked  incoherently  when 
left  alone,  and  towards  the  latter  part  of  the  day  began  to  make 
repeated  attempts  to  get  out  of  bed.  On  one  occasion  he  succeeded, 
and  walked  down  stairs,  from  his  bedroom  to  the  parlour.  His  tongue 
was  brown  and  dry.  Under  these  circumstances,  I  ordered  him  the 
mixture  containing  four  grains  of  tartar  emetic  and  one  drachm  of  lauda- 
num, in  eight  ounces  of  camphor  mixture ;  of  this  he  took  two  drachms 
every  second  hour.  The  efi'ects  produced  by  this  medicine  were  not 
very  rapid,  but  still  they  were  decidedly  beneficial,  for  he  gradually  be- 
came calmer,  wandered  less,  did  not  attempt  to  get  out  of  bed,  and, 
during  the  night,  got  some  sleep.  His  bowels  being  confined,  the 
mixture  was  now  laid  aside,  and  purgatives  exhibited ;  I  should  have 
remarked  that  the  tartar  emetic  mixture  caused  profuse  sweating. 

On  the  fifteenth  day  of  the  fever,  his  bowels  having  been  acted  on, 
he  was  ordered  twenty  drops  of  Battley^s  solution  of  opium  at  night, 
which  produced  a  comfortable  night^s  rest,  the  fii'st  he  had  enjoyed 
since  his  illness.  On  the  sixteenth,  the  sweating  continued,  the  belly 
was  fallen,  and  he  was  quite  rational,  but  had  marked  subsultus ;  he 
got  another  dose  of  Battle}^,  but  it  produced  no  sleep ;  he  had  been 
allowed  chicken-broth,  beer,  &c.  for  some  days.  On  the  seventeenth 
day,  the  sweating  had  ceased,  and  his  skin  had  become  hot  and  dry ; 
great  restlessness,    constant   muttering   delirium,    subsultus,   tremors, 


234  CLINICAL   ]\]EDICINE. 

picking  the  bed-clothes,  involuntary  discharges  :  porter  in  small  quan- 
tities, chicken-broth,  fetid  injection,  and  twenty  drops  of  Battley  at 
night.  On  the  eighteenth,  he  was  reported  to  have  had  no  stool  from 
the  injection,  and  no  sleep  whatsoever.  He  answered  incoherently, 
thought  his  bed  was  covered  with  lancets,  some  of  which  he  collected 
carefully,  and  reserved  for  me ;  belly  not  tumid,  but  obstinately  con- 
fined ;  pulse  100.  The  whole  of  that  day,  and  the  following,  were  em- 
ployed in  procuring  alvine  evacuations,  preparatory  to  again  giving 
opium  ;  in  the  mean  time,  all  his  symptoms  were  aggravated,  and  when 
I  visited  him  on  the  evening  of  the  nineteenth  day,  his  state  was  anx- 
ious in  the  extreme,  as  he  had  enjoyed  no  sleep  for  many  days  and 
nights,  and  was  in  a  melancholy  state  of  mental  incoherence,  raving, 
tremor,  and  subsultus. 

Here  came  the  crisis  as  to  treatment.  I  remember  well  the  time 
when  a  patient  so  situated  would  have  been  again  purged,  his  head 
shaved,  a  few  leeches  apphed  to  the  temples,  and  a  blister  to  the  nape 
of  the  neck,  while  perhaps  wine  and  musk  would  have  been  exhibited 
internally.  How  many  persons  have  I  seen  so  treated  by  the  most 
eminent  physicians,  and  how  unsuccessful  was  the  practice  !  To  have 
talked  of  giving  opium  under  such  circumstances,  and  when  the  marks 
of  cerebral  congestion  w^ere  so  evident,  would  have  been  regarded  as 
absurd ;  my  experience  on  former  occasions,  however,  determined  me 
to  give  opium,  and  as  the  danger  was  imminent,  I  gave  it  boldly.  To 
the  eight  ounce  mixture,  with  four  grains  of  tartar  emetic,  we  added 
one  drachm  and  a  half  of  laudanum ;  of  tliis  he  took  one  ounce  every 
second  hour,  from  eight  in  the  evening  until  he  had  taken  five  doses. 
This  produced  copious  sweating ;  the  skin  became  cooler,  he  raved  less, 
but  still  no  sleep ;  at  four  on  the  following  morning,  his  pulse  became 
70,  and  respiration  tranquil ;  he  got  twenty  drops  of  Battley,  and  at 
half-past  five  in  the  morning,  twenty-five  drops  more.  He  had  now 
taken,  within  a  short  time,  about  one  drachm  of  laudanum,  and  forty- 
five  drops  of  Battley,  combined  with  nearly  three  grains  of  tartar 
emetic.  He  was  tranquil,  but  did  not  close  his  eyes,  and  muttered 
occasionally  ;  subsultus  less.  His  pupils  now  became  more  and  more 
contracted,  his  eyes  less  expressive  and  duller,  and  when  I  came  at 
eight  in  the  morning,  he  w^as  evidently  deeply  narcotised,  although  not 
yet  asleep.  I  thought  that  all  was  lost  j  but  still,  observing  the  respi- 
ration to  be  tranquil,  and  the  pulse  regular,  I  indulged  a  faint  hope 
that  sleep  might  still  supervene.  His  eyes  now  became  still  more  inex- 
pressive, the  lids  gradually  closed,  his  breathing  became  prolonged  and 
deep,  and  at  half-past  eight  he  was  buried  in  a  profound  and  tranquil 
sleep,  which  continued  for  nine  hours,  when  he  awoke,  spoke  rationally. 


TARTAll  EMETIC  IN  LARGE  DOSES  IX  MALIGNANT  TEVER.  235 

said  he  had  no  pain  in  the  head,  took  some  drink,  and  fell  asleep  again. 
Next  morning  not  a  single  symptom  of  fever  remained. 

The  following  cases  prove  that  tartar  emetic,  in  considerable  doses, 
may  be  administered  with  advantage  at  a  period  of  fever  in  which  it 
was  usually  thought  to  be  inapplicable,  and  to  an  extent  which  even 
now  I  cannot  but  consider  as  remarkable.  When  I  first  used  tartar 
emetic  and  opium,  I  had  not  pushed  the  former  remedy  with  the  bold- 
ness and  decision  I  have  since  done,  for  my  experience  only  gradually 
accustomed  me  to  a  method  of  proceeding  contrary  to  preconceived 
opinions,  and  my  views  of  the  powers  of  the  remedy  only  gradually 
enlarged  as  I  became  more  confident  of  its  safety.  It  is  but  right  to 
add,  and  I  do  it  with  gratitude,  that  I  received  much  assistance  and 
encouragement  from  the  views  of  Dr.  Marryatt  of  Bristol,  pubhshed  in 
1788,  but  of  which  I  and  the  profession  in  Ireland,  and  I  may  add  in 
England,  were  generally  ignorant  until  they  were  noticed  in  the  first 
volume  of  \\\q  British  and  Foreign  Medical  Review,  page  416.  This 
notice  of  a  work,  of  which  I  had  never  before  heard,  and  the  testimony 
it  contained  that  tartar  emetic  may  be  exhibited  in  considerable  doses, 
and  with  advantage,  at  advanced  stages  of  malignant  fever,  led  me  to 
attach  more  importance  to  this  remedy  alone,  and  uncombined  with 
opium,  and  determined  me  to  adopt  a  bolder  line  of  practice  in  future, 
a  determination  which  the  event  fully  justified. 

Some  there  are  who  will  take  occasion  to  remark  that  I  can  have  no 
claim  to  originality  on  this  occasion.  But  all  who  have  watched  my 
practice  in  the  hospital,  nay,  aU  who  have  taken  the  trouble  of  reading 
my  lectures  and  successive  publications  on  this  subject,  will  at  once 
acknowledge  that  I  proceeded  on  this  path  of  investigation  with  no 
other  guide  but  an  analogy  derived  from  an  observation  of  the  effects 
of  tartar  emetic  and  opium  in  delirium  tremens,  a  disease  undescribed 
in  the  time  of  Marryatt.  Every  one  the  least  conversant  \yith  the  treat- 
ment of  fever  in  private  and  in  hospital  practice  in  Dublin,  London, 
and  Edinburgh,  will  allow  that  no  one  during  the  present  century  ever 
taught  or  practised  the  exhibition  of  tartar  emetic  at  the  stage  of  typhus 
fever  in  which  I  have  recommended  it.  Not  a  single  hint  at  such  a 
treatment  is  given  in  any  of  the  numerous  contributions  on  the  treat- 
ment of  typhus,  which  form  the  valuable  W'Ork  edited  by  Dr.  Barker 
and  Dr.  Cheyne.  Where  is  there  even  one  allusion  to  this  practice  in 
Armstrong,  Smith,  Tweedie  ?  And  what  is  said  of  it  in  Good,  Thomas, 
Mackintosh,  or  in  the  Cyclopaedia  of  Practical  Medicine  ?  Where  is 
it  mentioned  or  inculcated  in  the  Edinburgli  Medical  and  Surgical 
Journal,  or  in  Johnson^s  Medico-Chirurgical  Review  ?  No  where ; 
although  the  treatment  of  fever  is  often  the  subject  of  anxious  discussion. 


236  CLINICAL   MEDICINE. 

So  far  suffices  with  regard  to  tlie  novelty  of  tlie  matter,  for  it  is 
useless  to  argue  with  persons  so  stupid  as  to  confound  the  practice  I 
recommend  with  the  well  known  and  popular  use  of  tartar  emetic  as  an 
emetic  or  a  diaphoretic  in  the  commencement  of  febrile  diseases  gene- 
rally. That  I  did  not  come  upon  this  method  sooner,  I  regret  infinitely, 
for  since  its  adoption  my  practice  in  hospital  and  in  private  has  been 
.  much  more  successful  than  formerly.  Nay,  shortly  before  Mr.  Cook- 
son's  illness,  I  lost  several  of  my  friends,  relatives,  and  patients,  who 
would  in  all  probability  have  recovered  if  so  treated ;  and  among  the 
rest  a  gentleman,  the  very  week  before  the  first  trial  I  made  of  the 
practice  in  Mr.  Cookson's  case.  I  mention  this  fact  as  the  strongest  and 
most  convincing  proof  that  I  had  never  even  thought  of  tliis  method 
until  Mr.  Cookson's  case  occurred,  for  had  I  done  so  I  would  have 
surely  been  inexcusable  in  allowing  my  patients  to  perish  without  even 
trying  its  effects.     But  it  is  time  to  proceed  to  the  cases  themselves. 

A  case  occurred  very  lately  in  the  Meath  Hospital,  where  its  progress 
was  anxiously  watched  by  many  students  and  several  practitioners,  all 
of  whom  concurred  in  the  opinion  that  the  patient  must  have  died  had 
he  been  treated  according  to  the  plan  usually  followed  under  similar 
circumstances.  Tliis  patient  was  attended  under  my  directions  by  Mr. 
Harnett,  who  took  the  following  notes  of  its  progress,  and  visited  the 
patient  with  unremitting  attention  both  by  day  and  by  night. 

Joseph  Taylor,  aged  twenty-one,  a  strong  young  man,  of  temperate 
habits,  admitted  into  hospital  on  the  7th  May,  1836.  Ill  seven  days ; 
sickness  commenced  with  rigors,  headache,  pains  in  loins,  &c.  On  ad- 
mission he  complained  of  headache,  tinnitus  aurium ;  face  was  flushed; 
eyes  slightly  suffused;  was  constantly  frowning;  skin  hot  and  dry, 
slightly  maculated ;  abdomen  full  and  soft ;  bowels  confined. 

Habeat  Haustum  Rhei. 

9th.  Slept  pretty  well ;  raved  little ;  ringing  in  ears  continues ; 
headache  increased ;  eruption  of  the  maculae  much  more  copious ;  slight 
cough ;  some  bronchitic  rales  over  both  lungs ;  abdomen  in  every  re- 
spect natural ;  bowels  regular  ;  pulse  100,  distinctly  dicrotous  and 
sharp ;  tongue  brown,  dry,  rough  and  furred ;  had  sHght  epistaxis  tlu-ee 
days  ago. 

R     Pilulae  Hydrargyri,  gr.  iii. 

Pulveris  Ipecacuanhas,  gr.  ss. ;  Misce  fiat  pilula,  4tis  horis  sumenda. 
Applicentur  hirudines  duos  naribus,et  repetatur  applicatio  hirudinum 
vesper e  si  opus  sit. 

Tenth  day  of  fever.  Slept  tolerably  well ;  bled  copiously  from  nares ; 
pain  in  head  diminished ;  countenance  still  flushed  and  hot ;  temperature 


TARTAR  EMETIC  IX  LARGE  DOSES  IN  MALIGxNANT  FEVER.  237 

of  rest  of  body  lower  than  natural;  feet  very  cold;  pulse  112^  dicro- 
tous  and  wiry ;  tongue  parched  and  furred,  dark  brown,  great  difficulty 
in  protruding  it. 

Stupes  to  feet,  bHsters  to  praecordial  region ;  blisters  to  calves  of  legs 
in  the  course  of  the  day. 

R    Misturse  Camphorse,  f^i. 
Liquoris  Hoffmanni,  f3i ; 
Misce  fiat  haustus,  4tis  horis  sumendus. 

Eleventh  day.  Became  very  violent  yesterday  evening ;  attempted  to 
get  out  of  bed  frequently,  but  when  spoken  to  by  the  nurse,  he  re- 
mained quiet  for  a  short  time ;  was  constantly  raving,  and  gnashing 
his  teeth  during  the  night ;  had  no  sleep ;  a  short  time  before  visit  this 
morning  had  a  fit  of  an  epileptic  character,  which  lasted  about  ten 
minutes,  in  which  he  worked  violently,  and  foamed  at  the  mouth ;  at 
the  hour  of  visit,  nine  in  the  morning,  the  countenance  was  flushed, 
anxious,  and  expressive  of  great  ferocity ;  eyes  wild  and  suffused ;  pupils 
natural ;  complains  of  dimness  of  vision ;  eye-brows  contracted ;  breath- 
ing hurried ;  is  constantly  tossing  himseK  from  one  side  of  the  bed  to 
the  other,  and  tearing  the  dressings  off  the  blistered  surface ;  skin  hot 
and  dry :  abdomen  soft ;  no  tympanitis ;  bowels  loose ;  tongue  parched 
and  furred;  he  is  incessantly  protruding  and  biting  it,  and  gnash- 
ing his  teeth;  pulse  dicrotous,  very  quick,  and  sometimes  hard,  but 
small. 

R    Antimonii  Tartarizati,  gr.  vi. 
Aquae,  f^x.  ; 
Mucilaginis, 

Syrupi  Papaveris  albi,  aa.  f§i. ;  Misce,  fiat  mistura,  sumat  f^ss.omni 
semihora. 

Three  o'clock,  p.  m.  Has  taken  half  the  mixture,  was  nauseated  by 
the  second  dose,  but  not  since;  he  still  continues  very  violent;  fancies 
he  has  a  bone  in  his  mouth  which  he  is  constantly  biting;  is  in  a 
copious  perspiration  since  he  commenced  taking  the  medicine. 

Mr.  Harnet  ordered  ^i.  of  the  mixture  every  haK  hour. 

Six  o'clock,  A.  M.  Appears  a  little  calmer ;  has  taken  the  whole  of 
the  medicine,  no  nausea  produced;  has  bitten  his  tongue  and  lip 
severely ;  perspiration  continues ;  has  passed  a  large  quantity  of  urine 
in  bed ;  pulse  soft  and  full. 

R    Antimonii  Tartarizati,  gr.  iii. 
Aquae,  fSvss. 

Syrupi   simplicis,  fSss.      Misce,  fiat    mistura   cujus  sumat   f^ss.omni 
semihora. 

Eleven  o'clock,  p.  m.     Has  taken  aU  his  medicine  without  being 


238  CLINICAL  5IEDICINE. 

nauseated;  countenance  less  flushed;  is  constantly  raving ;  pulse  100, 

full  and  soft. 

R.     Antimonii  Tartavizati,  gr.  iv. 
Misturse  Camphorse,  f^viii. ; 
Tincturjc  Opii,  f5i.  Miscefiat  misturacujus  capiat  f^ss.  omni  semihora. 

12th.  Continued  raving  during  the  night;  had  no  sleep;  appears 
much  quieter  this  morning ;  face  less  flushed ;  eyes  still  wild  and  star- 
ing, but  very  shghtly  suffused;  brows  contracted;  pupils  natural; 
speaks  rationally;  pulse  80  and  regular,  has  lost  the  dicrotous  tone 
which  it  had  yesterday ;  bowels  confined. 

Habeat  enema  emolliens  :  et  repetatur  mistura  ; 
To  have  one  pint  of  porter  and  chicken  broth. 

Three  o^ clock  p.  m.  Having  taken  the  whole  of  the  mixture,  con- 
taining tartar  emetic  and  opium,  the  simple  tartar  emetic  mixture  was 
again  prescribed ;  after  taking  two  doses  of  which  he  fell  into  a  tranquil 
sleep,  in  which  he  is  at  present. 

Eight  0^ clock,  p.  M.     Has  slept  continually  all  day,  awakes  occa- 
sionally, but  falls  into  a  deep  sleep  very  soon  again. 
Omittatur  tinctura  opii. 

13th.  Slept  soundly  during  the  night ;  appears  calm  and  collected  ; 
conversation  quite  rational ;  maculae  have  disappeared ;  pulse  84,  soft 
and  regular  ;  omit  medicine ;  a  glass  of  porter  ;  light  nourishment. 

He  has  taken  more  than  twenty  grains  of  tartar  emetic  within  thirty 
hours,  and  has  been  nauseated  but  once. 

There  are  some  circumstances  in  this  case  which  require  to  be  con- 
sidered more  at  length.  In  the  first  place  it  is  well  to  bear  in  mind 
that  the  patient  was  affected  with  genuine  maculated  fever  the  true 
typhus,  in  the  form  many  years  present  in  Great  Britain  and  in  Paris ; 
for  in  the  latter  city  this  peculiar  eruption,  somewhat  resembling 
measles  in  the  crescentic  shape  of  the  blotches,  is  considered  quite 
pathognomic  of  typhus.  This  is  important,  particularly  with  reference 
to  the  use  of  tartar  emetic  in  such  large  quantities ;  again  it  is  worthy 
of  remark,  that  symptoms  of  collapse,  so  alarming  as  to  excite  con- 
siderable apprehensions,  and  calling  for  the  immediate  application  of 
bhsters  and  the  use  of  stimulants,  occurred  on  the  10th  day  of  the 
fever.  It  was  immediately  after  this  collapse  that  the  violent  cerebral 
excitement  commenced,  and  certainly  this  previous  collapse  left  an  im- 
pression on  my  mind  that  no  directly  evacuating  remedies  could  be 
borne ;  that  they  would  at  least  be  attended  by  great  danger  of  speedily 
reproducing  a  fatal  degree  of  debility ;  for  this  reason  I  did  not  repeat 
the  application  of  leeches. 


I 


TAllTAE  EMETIC  IN  LAKGE  DOSES  IN  MALIGNANT  EEVER.  289 

The  delirium  in  this  patient  was  extremely  violent^  requiring  the  use 
of  the  strait  waistcoat,  and  the  constant  superintendence  of  the  nurse ; 
the  contortions  of  face,  and  the  ferocity  of  his  countenance,  the  con- 
stant biting  of  his  tongue  and  lips,  presented  a  frightful  picture  of  ex- 
citement, wliich  evidently  could  not  be  controlled  except  by  the  prompt 
and  energetic  use  of  powerful  remedies.  As  the  blistered  surface  of  his 
chest  seemed  to  add  much  to  the  state  of  excitement,  for  he  was  con- 
stantly tearing  it,  I  did  not  think  of  applying  blisters  to  the  head,  being 
persuaded  that  they  might  aggravate  the  evil,  since  in  many  they  seem 
to  act  so  as  to  produce  a  sort  of  delirium  trmimaticum.  His  pulse 
being  frequent  and  sharp,  together  with  the  evident  determination  to 
the  brain,  seemed  to  indicate  the  exhibition  of  tartar  emetic,  nor  was 
there  any  thing  in  the  state  of  the  intestinal  canal  to  forbid  its  being 
given  in  frequently  repeated  doses.  The  result  more  than  realised  our 
expectations,  for  during  its  use  the  delirium  gradually  abated,  and  the 
pulse,  becoming  much  less  frequent  changed  its  character  from  a  short 
and  small,  to  a  full  soft  stroke.  This  prepared  the  way  for  the  safe 
trial  of  opium,  which  was  not  commenced  until  he  had  taken  twelve 
grains  of  the  tartar  emetic.  The  opium  was  afterwards  laid  aside,  and 
the  tartar  emetic  alone  completed  the  cure;  but  it  may  be  doubted 
whether  alone  it  would  not  have  induced  sleep. 

I  have  made  these  remarks  for  the  purpose  of  rectifying  an  erroneous 
impression,  wliich  I  fear  has  gone  abroad  concerning  the  use  of  tartar 
emetic  and  opium  in  the  delirium  of  fever,  and  to  prevent,  as  far  as  I 
can,  the  exhibition  of  opium,  except  when  certain  precautions  have  been 
taken  by  the  practitioner  to  remove  or  diminish  cerebral  congestion  by 
means  of  proper  evacuations  or  tartar  emetic.  No  man  can  justly  be 
held  responsible  for  the  abuse  by  others  of  remedies  he  recommends ; 
but  since  the  publication  of  my  observations  on  this  subject,  I  have  had 
lamentable  proofs  that  I  have  been  misunderstood ;  and  lately  was  called 
to  see  a  gentleman  in  the  vicinity  of  Dublin,  who,  the  practitioner  in 
attendance  said,  had  been  treated  according  to  my  method,  whereas  the 
patient  was  killed,  according  to  his  own,  by  opium  injudiciously  given 
during  delirium  with  evident  cerebral  congestion. 

It  has  been  asserted,  that  after  all,  this  case  was  not  so  dangerous, 
nor  its  recover}^  very  remarkable.  Tor  a  full  refutation  of  so  groundless 
an  opinion,  I  refer  with  confidence  to  the  written  history  of  the  case 
itself,  a  history  which  is  far  from  laying  before  you  an  adequate  picture 
of  the  deplorable  state  of  the  patient  at  the  time  that  my  treatment  was 
about  to  be  commenced,  but  wliich,  nevertheless,  is  still  faithful  enough 
to  convince  every  one  at  all  acquainted  with  the  symptoms  and  progress 
of  fever,  that  the  case  was  almost  hopeless.     What !  is  it  possible  that 


240  CLINICAL    MEDICINE. 

any  one  can  be  founds  who  has  witnessed  fifty  cases  of  bad  fever,  and 
who  is  bold  enough  to  say,  that  because  the  patient  is  young  and  was 
previously  healthy,  he  could  not  be  considered  in  imminent  danger, 
when  on  the  tenth  day  of  spotted  fever,  a  state  of  collapse  requiring 
blisters  and  stimulants  is  followed  on  the  eleventh  day  by  deHrium  of 
the  most  violent  description,  rendering  it  necessary  to  tie  the  patient 
down  in  bed,  and  accompanied  by  a  fit  of  convulsions  of  frightful  vio- 
lence, lasting  more  than  ten  minutes,  and  resembling  an  epileptic  sei- 
zure? 

This  last  symptom  alone  is  more  than  enough  to  denote  extreme  dan- 
ger. 'Foi  the  truth  of  this  assertion  I  appeal  to  my  own  experience,  to 
the  experience  of  every  practical  man,  and  to  the  writings  of  every  au- 
thor who  has  written  on  fever.  Hippocrates  has  four  aphorisms,  all 
testifying  the  danger  of  convulsions  in  fever ;  and  in  his  book  of  prog- 
nostics, he  says,  that  various  causes  may,  in  fever,  produce  convulsions 
in  children  under  seven  years  of  age,  without  great  danger  to  life ;  but 
he  adds  with  great  emphasis,  in  adults,  convulsions  never  take  place 
unless  ^^  ri  TOJV  67]fjjU0)v  ir^otsyivrirat  tmv  tff^v^orraruv  rs  xai  KciTtigTUV."  It  is 
scarcely  possible  to  describe  the  danger  of  any  thing  in  stronger  terms 
than  these. 

Those  who  assert  that  the  possession  of  previous  good  health,  or  of  a 
robust  frame,  renders  violent  fevers  less  dangerous,  know  little  of  the 
matter.  The  strongest  and  most  powerful  men  I  ever  knew  were  Dr. 
Clarke,  Jun.,  and  Dr.  Duigenan ;  they  both  died  before  the  end  of  the 
third  day ! 

I  cannot  pass  over  in  silence  the  remark,  that  my  cases  only  prove 
how  much  the  powers  of  nature  are  able  to  bear,  an  observation  involv- 
ing the  insinuation  that  I  was  very  culpable  in  giving  such  an  example 
to  others,  and  in  countenancing  the  exhibition  of  strong  medicines,  such 
as  tartar  emetic  in  unwarrantably  large  doses.  Now  with  all  due  defe- 
rence, I  may  be  permitted  to  observe,  that  in  acute  diseases  threatening 
immediate  danger  to  Hfe,  we  gain  little  by  waiting  for  Nature's  assist- 
ance. Powerful  remedies  must  be  employed ;  but  mark,  if  they  are  em- 
ployed judiciously,  tkeir  powers  are  only  exerted  in  controlling  the 
disease ;  this  happened  in  all  the  cases  I  have  related,  none  of  the 
patients  were  injured  in  any  way ;  in  truth  the  physician  who  orders  one- 
fourth  or  one-half  of  a  grain  of  tartar  emetic  to  be  given  repeatedly  until 
the  disease  yields,  and  who  diminishes  the  frequency  of  the  dose  and 
the  quantity  of  the  medicine,  in  proportion  to  the  diminution  of  the 
symptoms,  to  curb  which  was  his  object,  that  physician  cannot  be  justly 
accused  of  giving  heroically  large  doses  of  the  medicine  in  question. 
To  give  it  in  smaller  and  less  frequently  repeated  doses  than  are  found 


TARTAE   EMETIC    IN    LAEGE    DOSES    IN    MALIGNANT   FEVEE.         241 

sufficient  to  make  an  impression  on  the  symptoms  would  be  mere  tri- 
fling. The  doses  of  medicines  must  be  pronounced  to  be  large  or  small 
not  according  to  their  weight  or  measure^  but  according  to  their  effects, 
and  when  confessedly  moderate  doses  are  frequently  given,  and  the  effects 
of  each  carefully  watched,  surely  caution  herself  can  require  no  more. 
The  same  remark  applies  to  my  directions  concerning  opium. 

The  next  case  I  have  peculiar  satisfaction  in  laying  before  you,  inas- 
much as  its  progress  and  treatment  were  witnessed  by  Sir  P.  Crampton, 
who  was  struck  by  the  benefit  resulting  from  a  mode  of  practice  he  had 
never  before  seen  applied,  and  that,  under  circumstances  which  he  con- 
sidered as  indicative  of  the  greatest  danger.  Dr.  Campbell  too  had  an 
opportunity  of  witnessing  for  the  first  time  this  mode  of  treatment,  and 
he  since  assured  his  class,  that  when  I  recommended  it,  he  had  scarcely 
a  hope  that  our  patient's  life  could  be  saved. 

Mr.  C,  residing  in  Eitzmlliam-square,  a  surgeon,  formerly  an  ap- 
prentice of  the  Surgeon- General,  a  young  man  of  a  powerfully  athletic 
make,  was  attacked  with  the  rigor  of  fever  on  Monday,  9th  May,  1836. 
He  was  attended  from  the  commencement  by  Dr.  Campbell,  and  had  a 
copious  eruption  of  measles-like  maculae  on  the  sixth  day  of  the  fever, 
when  I  first  saw  him.  No  unusual  symptom  occurred  on  the  seventh 
day,  and  the  headache,  of  which  he  complained  much  at  the  commence- 
ment, had  disappeared  in  consequence  of  the  application  of  a  few  leeches. 
On  the  morning  of  the  eighth  day  we  observed  that  every  now  and  then 
he  respired  irregularly,  as  if  repeatedly  and  gently  sighing,  a  variety  of 
respiration  often  indicating  a  disturbance  of  the  nervous  system,  and 
which  I  have  repeatedly  observed  as  a  precursor  of  cerebral  excitement, 
and  to  which,  consequently,  I  have  been  in  the  habit  of  drawing  your 
attention,  under  the  name  of  cerebral  respiration. 

On  the  afternoon  of  the  eighth  day  we  had  the  benefit  of  Sir  P. 
Crampton's  advice,  who  thought  his  case  a  very  bad  one  indeed,  for  his 
pulse  was  almost  140  in  a  minute,  and  remarkably  shabby,  while  he  lay 
on  his  back  thickly  covered  with  maculae ;  and  we  found  tliat  a  rapid 
tumefaction  of  the  abdomen  had  commenced  within  a  few  hours  :  a  very 
bad  symptom  inasmuch  as  the  beUy  had  been  in  the  morning  quite  soft 
and  fallen,  and  there  was  no  cause  to  account  for  the  sudden  develop- 
ment of  tympanitis,  unless  we  supposed  it,  as  it  too  frequently  is,  a  har- 
binger of  dissolution  at  no  very  distant  period.  His  tongue  was  parched, 
and  he  complained  of  thirst.  The  usual  treatment  by  means  of  chloride 
of  soda  was  determined  on,  in  consultation ;  after  which  Sir  P.  Crampton 
expressed  to  the  gentleman's  friends,  the  fears  he  entertained  for  the  re- 
sult. Scarcely  had  he  gone  out  of  the  house,  and  just  as  Dr.  Campbell  and 
I  were  preparing  to  leave  it,  when  a  sudden  change  took  place  in  our 

VOL.  I.  16 


242  CLINICAL    MEDICINE. 

patient,  who  jumped  out  of  bed,  and  nearly  succeeded  in  throwing  him- 
self out  of  a  garret-window.  We  found  him  violently  delirious ;  but 
this  state  did  not  last  for  more  than  a  few  minutes,  when  it  subsided 
into  a  delirium  of  a  comparatively  gentler  description.  He  refused, 
however,  to  return  to  bed,  and  we  were  obhged  to  allow  him  to  walk 
about  in  his  shirt,  supported,  for  he  was  feeble,  by  two  attendants ;  his 
eyes  became  at  times  very  prominent  and  ferocious ;  now  and  then  he 
threatened  all  those  about  him,  in  a  loud  and  terrifying  tone  of  voice, 
and  he  seemed  every  moment  on  the  border  of  frantic  madness.  No- 
thing could  induce  him  to  go  to  bed,  or  allow  even  a  blanket  to  be 
thrown  over  his  cold  and  naked  extremities.  Thus,  seated  on  his 
chair  he  presented  a  frightful  picture,  while  his  pulse  became  so  quick, 
that  it  could  scarcely  be  counted,  and  was,  at  the  same  time  exceedingly 
weak. 

What  was  to  be  done  ?  The  state  of  his  circulation  did  not  admit  our 
endeavouring  to  control  the  cerebral  excitement  by  arteriotomy  or  even 
leeches,  and  the  last  remark  Sir  P.  Crampton  made,  was,  that  a  very  few 
leeches  would  kill  him ;  bhsters  would  be  too  slow  in  their  action,  and 
might  even  aggravate  the  disease ;  cold  effusion  seemed  inadmissible. 
In  short,  it  seemed  that  our  patient  was  beyond  the  reach  of  all  resources; 
as  to  tartar  emetic,  I  felt  at  first  unwilling  to  order  it  on  my  own  respon- 
sibility, in  a  case  apparently  so  desperate,  and  after  Sir  P.  Crampton  had 
left  the  house  ;  in  fact  neither  Dr.  Campbell  nor  I  thought  it  probable 
that  our  patient  would  survive  twelve  hours :  yet  as  I  saw  no  possible 
means  of  saving  him  but  the  tartar  emetic  treatment,  and  determined  at 
all  risks  to  make  a  strenuous  effort,  I  did  not  think  myself  justified  in 
any  longer  hesitating  about  the  matter,  and  ordered  a  mixture  containing 
one  ounce  of  syrup  of  white  poppies,  one  of  mucilage,  and  six  of  water, 
with  eight  grains  of  tartar  emetic.  Of  this  solution  he  was  to  get  half 
an  ounce  every  half  hour,  until  a  manifest  impression  on  the  cerebral 
excitement  was  produced. 

The  medicine  was  administered  by  the  late  Mr  Ferguson  of  Kildare- 
street,  who  told  me  afterwards  that  he  was  quite  surprised  at  the  treat- 
ment adopted,  and  was  sure  that  neither  it  nor  any  other  could  save  Mr. 
C'^s  hfe.  The  first  six  doses  seemed  to  sicken  him  a  little,  but  he  did 
not  vomit  until  after  the  seventh  dose ;  the  eighth  also  produced  very 
copious  vomiting  of  mucous  and  bilious  fluid.  After  the  second  vomit- 
ing he  was  prevailed  on  to  go  to  bed,  and  was  evidently  more  tranquil, 
but  from  having  remained  up  uncovered  for  so  many  hours,  much  trouble 
was  necessary  before  warm  apphcations  succeeded  in  restoring  the  natural 
temperature  of  his  limbs  and  skin  generally. 

At  10  p.  M.  we  saw  him  again,  and  finding  that  the  medicine  had 


TARTAR   EMETIC    IN    LARGE    DOSES    IN    MALIGNANT   FEVER.        243 

produced  so  powerful  an  effect,  we  ordered  it  to  be  repeated  only  every 
second  hour. 

May  18th — Ninth  day  of  fever  :  8  a.  m.  Has  taken  five  doses  since 
last  visit ;  stomach  quiet  since  the  eighth  dose.  He  slept  several  hours 
quietly  in  the  beginning  of  the  night,  (he  had  not  slept  for  several  nights 
before,)  but  seems  more  excited  now ;  he  threatens  some  of  his  attend- 
ants, and  appears  likely  to  be  unruly.  It  was  therefore  judged  right  to 
repeat  the  medicine  every  hour  and  a  half. 

1  p.  m.  Has  taken  eight  grains  of  tartar  emetic  since  six  o^ clock  yes- 
terday evening.  A  solution  of  the  same  strength  in  plain  water  was  now 
directed  to  be  given  in  the  dose  of  half  an  ounce  every  fourth  hour.  He 
slept  a  good  deal  during  the  day,  and  the  medicine  operated  on  the 
bowels,  bringing  down  very  large  fluid  stools,  consisting  of  a  great  quan- 
tity of  healthy  yellow  fsecal  matter.  This  effect  is  often  produced  by  the 
tartar  emetic  in  the  advanced  stages  of  fever,  and  is  always  a  good  sign. 
Although  he  was  evidently  more  tranquil  than  before,  it  was  thought 
advisable  still  to  keep  two  strong  steady  men  constantly  in  the  room, 
ready  to  assist  the  nurse  in  case  of  emergency.  He  still  raved  occasion- 
ally, and  would  not  allow  certain  persons,  me  among  the  rest,  to  approach 
him,  having  conceived  a  strong  aversion  for  us. 

At  7  p.  M.  we  found  that  the  fever  was  again  rising,  and  that  the 
cerebral  excitement  was  on  the  increase ;  we  therefore  again  had  recourse 
to  half-hour  doses,  until  the  excitement  yielded ;  after  which  it  was  given 
only  every  second  hour. 

May  19tli. — Tenth  day  of  fever :  10  a.  m.  He  took  six  doses  during 
the  niglit.  He  got  out  of  loed  and  eluded  the  vigilance  of  liis  attendants 
at  a  very  early  hour  in  the  morning,  but  walked  peaceably  about  the 
house,  and  when  asked  returned  quietly  to  bed.  He  slept  well  afterwards. 
As  so  much  had  been  gained,  we  thought  it  unnecessary  to  persevere  in 
the  use  of  the  tartar  emetic ;  it  was  discontinued.  He  took  in  all  twelve 
grains ;  it  diminished  the  frequency  of  the  pulse  notably ;  and  what  was 
very  striking  during  the  forty-eight  hours  we  employed  it,  the  pulse  not 
only  became  slower,  but  much  softer  and  much  fuller ;  the  skin  became 
softer  and  moist ;  the  belly  was  fallen  and  soft ;  and  the  maculae  much 
diminished.  His  fever,  notwithstanding,  still  continued ;  he  spoke  in- 
coherently, but  did  not  again  get  out  of  bed. 

On  the  fourteenth  day  an  evident  abatement  of  general  fever  com- 
menced ;  the  pulse  fell,  and  the  respiration,  which,  when  he  was  at  the 
worst,  had  been  about  fifty  in  a  minute,  fell  to  twenty-five.  This  im- 
provement continued  progressive,  and  on  the  seventh  day  precisely,  all 
fever  left  him;  his  pulse  being  then  60. 

The  after  treatment  consisted  merely  in  giving  a  mild  aperient  every 


244  CLINICAL    MEDICINE. 

second  day^  until  convalescence  commenced.  After  the  use  of  the  tartar 
emetic  had  cured  the  cerebral  excitement^  he  slept  almost  continually 
until  the  termination  of  the  fever. 

The  next  case  is  that  of  Mr.  M.,  a  gentleman  of  sedentary  habits,  full 
and  corpulent,  40  years  of  age,  who  was  lately  attacked  with  violent 
symptoms  of  fever.  He  was  very  actively  and  judiciously  treated  by 
Dr.  Ireland  from  the  commencement.  The  measles-hke  eruption,  ap- 
peared about  the  fifth  day.  He  had  been  copiously  bled  from  the  arm 
twice,  and  leeches  were  repeatedly  applied  to  the  forehead  for  the  purpose 
of  relieving  pain  in  the  head.  He  was  likewise  very  freely  purged.  About 
the  time  the  eruption  appeared,  his  restlessness  and  debility  increased, 
and  he  scarcely  slept  at  night.  In  the  course  of  a  few  days  his  state  had 
become  very  alarming,  and  I  saw  him,  in  consultation  with  Dr.  Ireland, 
on  the  ninth  day  of  his  fever. 

We  found  that  he  had  raved  constantly  during  the  preceding  night, 
and  was  bathed  in  an  exhausting  perspiration,  while  the  pulse  rose  to 
about  130 ;  liis  perspiration  was  very  frequent,  and  his  face  wore  an 
evident  expression  of  excitement,  not  of  a  violent,  but  of  a  very  restless 
character.  His  tongue  was  parched,  and  his  body  thickly  covered  with 
maculse.  In  short,  notwithstanding  the  active  measures  of  depletion, 
general  and  local,  applied  in  the  beginning  of  the  disease,  it  was  evident 
that  cerebral  excitement  had  come  on,  and  that  too  at  a  period  of  fever 
when  debility  forms  a  considerable  obstacle  to  the  further  use  of  direct 
evacuants.  His  exceedingly  gross  habit  of  body,  and  prominent  abdo- 
men, were  concomitants  of  the  worst  omen,  for  it  is  well  known  that 
very  fat  people  seldom  recover  from  typhus  of  a  bad  character.  In  this 
state  of  things  tartar  emetic  was  given  to  about  the  extent  of  three  grains 
in  the  twenty-four  hours ;  it  was  continued  forty-eight  hours,  or  until  a 
satisfactory  calm  of  the  nervous  system  had  been  produced.  Besides 
diminishing  the  delirium  and  inducing  sleep,  the  remedy  here  brought 
away  numerous  and  copious  bilious  stools,  and  diminished  notably  the 
frequency  of  the  pulse  and  of  the  respiration.  It  is  worthy  of  remark 
also,  that  in  proportion  as  he  came  under  the  influence  of  the  tartar 
emetic,  the  useless  and  profuse  perspiration  began  to  abate,  and  after 
some  hours  ceased. 

This  gentleman's  hfe  was  evidently  saved  by  the  treatment,  for  though 
his  fever  continued  many  days  after,  yet  he  never  was  in  danger  except 
from  hiccup,  which  came  on  about  the  thirteenth  day,  and  tormented  him 
day  and  night.  Claret — iced,  seemed  to  have  more  power  in  relieving 
this  symptom  than  any  other  expedient  resorted  to.  His  fever  terminated 
about  the  nineteenth  day. 
.  Dr.  Ireland,  who  has  had  the  most  extensive  experience  in  fever,  tes- 


TARTAE  EMETIC  IN  LARGE  DOSES  IN  MALIGNANT  FEVER.  245 

tified  the  pleasure  he  felt  at  witnessing  the  good  effects  of  a  mode  of 
cure  to  him  quite  new,  and  applied  in  a  case  he  thought  almost  desperate. 

The  following  case  presents  so  striking  and  convincing  an  illustration 
of  the  efficacy  of  my  treatment,  that  I  have  thought  it  right  to  lay  it 
before  you  also.  The  progress  of  the  case  was  witnessed  by  several  prac- 
titioners, who  all  declared,  and  I  myself  concurred  in  this  opinion,  that 
nothing  would  save  the  patient's  hfe.  His  recovery,  was  without  exag- 
geration, a  matter  of  astonishment  to  us  all ;  while  at  the  same  time  it 
was  so  evidently  the  effect  of  the  remedies  employed,  that  many  who  had 
been  wavering  in  their  minds  as  to  the  utility  of  tartar  emetic  exhibited 
in  the  advanced  stages  of  spotted  fever,  could  no  longer  refuse  their 
assent,  and  unhesitatingly  declared  their  conviction  that  by  no  other  plan 
of  treatment  could  a  favourable  issue  have  been  brought  about.  The 
patient  was  most  diligently  watched  by  Mr.  Eooney,  an  attentive  pupil, 
who  visited  him  many  times  during  the  day  and  night,  and  reported  to 
me  the  effect  of  the  medicines. 

Edward  Meylagh,  a  stout,  muscular  peasant,  aged  25,  was  attacked 
about  the  23d  May,  1836,  with  the  usual  symptoms  of  commencing 
typhus.  He  was  admitted  into  the  Meath  Hospital  on  the  1st  of  June 
after  the  usual  hour  of  visiting  the  wards.  It  was  ascertained  that  he 
had  been  repeatedly  and  violently  purged  since  the  commencement  of  his 
illness  by  piUs  and  aperient  mixtures.  I  saw  him  at  9  a.  m.  on  the  2d 
of  June :  he  had  passed  a  most  restless  night,  muttering  incessantly,  and 
becoming  at  times  so  unmanageable,  that  it  was  necessary  to  put  on  the 
strait  waistcoat.  Now  he  is  obstinately  silent,  wiU  not  answer  questions, 
or  put  out  his  tongue  when  desired.  His  countenance  is  at  once 
morose  and  haggard,  and  at  times  assumes  a  suspicious,  ferocious  aspect; 
eyes  glazed,  and  slightly  suffused ;  general  surface  of  skin  rather  dry  and 
hot,  but  his  extremities  are  cold  and  livid;  pulse  132,  small  and  com- 
pressed ;  respirations  42  irregular ;  abdomen  neither  swollen  nor  tender ; 
he  passes  urine  and  faeces  in  bed ;  his  tongue  is  dry,  and  dark-brown  in 
centre,  moist  and  red  towards  the  edges.  The  whole  surface  of  his  body 
is  covered  with  maculae.  Immediate  attention  was  paid  to  restore  the 
warmth  of  the  extremities,  and  I  directed  him  to  get  every  hour  half  an 
ounce  of  a  mixture,  consisting  of  eight  ounces  of  water,  four  grains  of 
tartar  emetic,  and  two  scruples  of  laudanum. 

1  P.  M.  At  mid-day  he  began  to  gnash  his  teeth,  knit  his  brows, 
screw  his  Hps,  and  spit  at  every  person  that  approached  his  bed.  The 
expression  of  the  face  was  rendered  worse  by  the  rapid'  motions  of  the 
eyeballs  and  a  frequent  squinting.  In  fact  he  became  so  ungovemable 
that  the  restraint  of  a  strait- waistcoat  was  no  longer  sufficient,  and  his 
legs  and  thighs  were  tied  down  to  the  bed.     His  carotids  pulsated  vio- 


246  CLINICAL   MEDICINE. 

lently,  and  he  alternately  laughed  and  screamed  aloud.  Pulse  132, 
still  small  and  wiry.  As  no  perceptible  action  had  been  produced  by 
the  medicine,  it  was  ordered  in  double  doses. 

6  p.  M.  Countenance  much  improved ;  less  morose ;  he  continues, 
however,  to  speak  unconnectedly,  but  jocularly ;  is  in  a  copious  warm 
perspiration  :  pulse,  120,  soft  and  compressible;  respirations  36,  regu- 
lar.    To  continue  the  double  doses. 

9  p.  M.  Has  been  in  a  composed  tranquil  sleep  since  liaK-past  six 
o'clock ;  perspiration  continues ;  has  passed  a  large  quantity  of  urine ; 
extremities  are  now  naturally  warm  and  moist :  the  pulsation  of  the 
carotids  has  subsided.  He  has  taken  four  grains  and  a  half  of  tartar 
emetic  since  morning,  and  twenty-three  drops  of  laudanum.  The  medi- 
cine was  now  directed  not  to  be  given  at  regular  intervals  as  before,  but 
according  as  the  symptoms  seem  to  require  it ;  it  had  neither  nauseated 
nor  purged  him. 

3rd  June.  He  has  slept  tolerably  during  the  night,  and  got  three 
doses  of  the  bottle.  About  five  in  the  morning  he  became  somewhat 
restless,  when  a  double  dose  was  immediately  administered,  after  which 
he  slept  composedly  until  nine  o'clock,  the  hour  of  visit.  His  tongue 
is  red,  dry,  and  parched,  fissured  towards  the  tip ;  his  thirst  is  increased, 
and  he  drinks  very  freely  of  cold  water ;  skin  moist  and  warm ;  pulse 
96,  dicrotous ;  respirations  30,  regular ;  he  seems  inclined  to  sleep. 
His  ideas  are  somewhat  confused,  although  he  answers  rationally; 
bowels  confined ;  abdomen  a  little  tumid  and  slightly  tympanitic.  Has 
taken  two  grains  and  a  half  of  tartar  emetic  and  ten  drops  of  laudanum 
since  yesterday  evening.  I  now  thought  it  unnecessary  to  persevere 
any  longer  in  the  use  of  this  mixture,  and  directed  my  attention  to  the 
state  of  the  bowels,  which  soon  yielded  to  emollient  lavements.  The 
alvine  evacuations  so  procured  were  very  copious,  and  were  followed  by 
immediate  subsidence  of  the  belly,  and  evident  amelioration  of  the 
symptoms.  He  continued  to  sleep  quietly  during  the  day ;  at  six  in 
the  evening  his  pulse  was  90,  soft  and  natural ;  respirations  30  ;  skin 
warm  and  perspiring ;  maculse  have  nearly  disappeared. 

7th  June.  Much  natural  sleep ;  pulse  65,  soft,  of  good  strength,  and 
without  any  of  the  dicrotous  character ;  intellectual  faculties  rapidly 
improving ;  now  passes  urine  and  fseces  voluntarily ;  abdomen  soft  and 
fallen ;  tongue  cleaning,  and  nearly  moist.  In  fact,  convalescence  has 
almost  commenced. 

With  one  case  more  I  shall  conclude.  A  gentleman  about  20  years 
of  age,  was  attacked  with  measles  of  an  irregular  form.  The  eruption 
did  not  come  out  favourably ;  and  notwithstanding  he  was  treated  from 
the  beginning  by  the  late  Dr.  O'Brien,  so  well  known  as  an  excellent 


TARTAR   EMETIC    IN    LARGE    DOSES    IN    MALIGNANT   FEVER.        247 

writer  on  the  subject  of  fever,  his  state  became  daily  worse,  and  Dr. 
O^Brien  pronounced  his  case  hopeless  when  he  sent  for  me  on  the  sixth 
day.  It  must  be  borne  in  mind  that  Dr.  O'Brien  was  Physician  to  the 
Cork-street  Pever  Hospital  for  thirty  years. 

The  combination  of  symptoms  which  caused  him  to  form  tliis  un- 
favourable opinion,  was  an  exceedingly  rapid,  shabby  pulse,  violent 
delirium,  total  sleeplessness,  and  an  evident  sinking  of  the  vital  powers, 
manifested  by  coldness  of  the  skin,  &c.  &c.  As  he  was  young,  and  the 
disease  recent,  we  ventured  to  draw  a  little  blood  from  the  arm,  but  he 
fainted  before  many  ounces  could  be  obtained ;  we  leeched  his  forehead 
without  any  perceptible  effect.  On  the  morrow  he  was  worse  :  I  then 
proposed  the  exliibition  of  small  doses  of  tartar  emetic,  in  frequently 
repeated  doses.  He  took  two  grains  in  the  course  of  ten  hours ;  was 
nauseated  or  vomited  by  almost  every  dose ;  became  more  tranquil ; 
finally  fell  asleep ;  and  in  twenty-four  hours  was  out  of  danger. 

Dr.  O'Brien  expressed  to  be  in  the  strongest  terms  his  gratification 
and  surprize  at  the  striking  and  beneficial  application  of  a  medicine  he 
had  never  before  seen  given  in  like  circumstances. 

Another  case  of  spotted  fever,  to  which  I  was  called  by  Mr.  M'Nalty 
of  Britain-street,  afforded  an  equally  favourable  result  within  this  last 
week ;  as  did  also  a  very  dangerous  case  of  the  same  disease,  which  I 
treated  along  with  Mr.  Mulock. 

I  have  thus  fully  brought  forward  the  result  of  my  experience  on 
this  subject,  convinced  that  I  have  not  deviated  in  the  slightest  degree 
from  the  strict  and  naked  truth  in  any  of  the  preceding  details.  I 
have  not  in  a  single  instance  related  what  was  not  witnessed  by  other 
medical  men  of  judgment,  well  known  to  the  profession.  If  my  treat- 
ment be  not  useful,  it  has  singularly  deceived  me  in  curing  my  patients. 
If  it  be  not  new,  it  is  strange  that  so  many  others  in  Dublin,  that  the 
whole  body  of  practitioners,  should  have  been  fully  as  ignorant  of  it  as 
I  was  myself. 

I  need  scarcely  again  observe,  that  the  proportions  of  the  two  pow- 
erful medicines  which  compose  this  mixture  must  vary  according  to  the 
circumstances  of  the  disease,  and  the  age  of  the  patient.  In  young 
persons  of  tender  age,  the  opium  must  be  given  in  smaller  quantities. 

Before  concluding  I  may  mention,  that  since  this  practice  was  first 
proposed,  it  has  continued  to  afford  me  the  greatest  satisfaction,  and 
that  I  have  reason  to  believe  that  those  who  have  employed  it  in  this 
country,  and  at  the  other  side  of  the  channel,  have  had  no  reason  to 
lose  confidence  in  it. 

In  a  paper  on  typhus  fever,  by  Dr.  Kilgour,  we  find  that  the  expe- 
rience of  Dr.  Dyce,  of  the  Aberdeen  Infirmary,  is  strongly  in  favour  of 


248  CLINICAL   MEDICINE. 

tliis  practice.  He  says,  "Tor  months  togetlier  the  pulmonic  symptoms 
prevailed  almost  entirely,  then  came  those  marked  by  gastric  and  intes- 
tinal irritation,  and  less  often,  though  still  continuing  for  a  length  of 
time  in  succession,  those  with  high  cerebral  action.  The  first  set,  as  is 
too  weU  known,  were  by  far  the  most  intractable  and  fatal ;  the  last, 
though  sufficiently  alarming,  and  always  requiring  restraint,  were  more 
amenable  to  treatment  than  either  of  the  others,  if  anticipated  in  their 
approach,  or  seen  soon  after  their  onset.  By  the  way,  the  medicine  I 
solely  relied  on  in  this  latter  class,  you  do  not  include  among  your 
list—/  mean  tartar  emetic.  Given  as  described  hy  Br.  Graves  ;  I  have 
found  it  eminently  successful^  and  have  the  greatest  confidence  in  it** — 
Edinburgh  Medical  and  Surgical  Journal,  Yol.  56,  p.  389. 

And  in  the  Eleventh  Yolume  of  the  Dublin  Medical  Journal, 
you  will  find  an  interesting  paper  on  ^'  Certain  Remedies  in  Typhus 
Eever,"  by  Dr.  Hudson,  of  Navan.  Speaking  of  the  treatment  by 
tartar  emetic  and  opium,  he  says,  "  It  seems  best  adapted  to  that  rest- 
less kind  of  delirium  tremens,  in  which  the  patient  cannot  be  restrained 
from  attempting  to  leave  his  bed,  and  walk  about  the  ward ;  when 
every  muscle  is  tremulous,  the  eye  is  red  from  want  of  sleep,  the  tongue 
dry,  and  the  patient  presenting  that  kind  of  spurious  excitement  which 
might  induce  the  attendant  (injudiciously,  no  doubt)  to  order  the  local 
abstraction  of  blood,  by  leeching  the  temples,  or  opening  the  temporal 
artery.  I  could  here  give  reports  from  my  note  book  of  several  cases 
thus  treated,  but  that  I  consider  it  would  be  rendering  tedious  a  paper 
already  too  long.  In  prescribing  this  medicine,  I  find  it  advisable  to 
use  great  caution  in  two  ways :  1st,  Not  to  give  it  after  it  has  produced 
sleep ;  2nd,  To  follow  it  up  by  the  prompt  and  frequent  exhibition  of 
wine,  and  such  nourishment  or  cordials  as  the  more  or  less  advanced 
stage  of  the  disease,  and  debihty  of  the  patient  may  require ;  as  it  seems 
to  me  that  there  is  increased  risk  of  the  patient  sinking  unless  timely 
supported  after  sleep  thus  induced.^' 

To  conclude,  I  must  observe  that  I  by  no  means  wish  to  recommend 
tartar  emetic  as  a  specific  in  fever.  I  only  use  it  in  the  complication 
above  described.  In  fever  the  physician  must  use  an  almost  endless 
variety  of  treatment  according  to  the  circumstances  of  the  individual 
case  before  him ;  and  he  only  will  be  successful  who  watches  narrowly 
the  progress  of  the  cases  intrusted  to  his  care,  and  applies  the  appro- 
priate remedies  at  the  proper  moment.  Bleeding,  leeches,  purgatives, 
mercurials,  absorbents,  acids,  stimulants,  tonics,  blisters,  cliloride  of 
soda,  may  each  be  necessary  in  the  treatment  of  different  cases  at 
diff'erent  stages  of  their  progress,  or  in  different  types.  In  fine,  the 
treatment  of  fever  will  be  always  difficult — always  complex,  but  it 
ought  to  be  successful. 


249 


LECTURE  XIX. 


THE   ADMINISTRATION   OF   WINE   IN   FEVER. — SEQUELS   OF   FEVER. 


I  CANNOT  conclude  the  remarks  I  have  to  make  on  different  points  con- 
nected with  the  treatment  of  fever,  without  directing  your  attention,  in 
an  especial  manner,  to  the  phenomena  of  the  hearfs  action  as  an  index 
for  the  administration  of  wine.  In  the  Eifteenth  Yolume  of  the  first 
series  of  the  Dublin  Medical  Journal  you  will  find  a  paper  on  tliis  sub- 
ject from  the  pen  of  my  distinguished  colleague  Dr.  Stokes.  Erom 
numerous  observations  he  concludes  that  certain  phenomena,  which  I 
shall  presently  detail,  indicate  a  softened  state  of  the  heart,  and  that  as 
soon  as  these  phenomena  present  themselves,  we  should  resort  to  stimu- 
lation by  wine,  &c.  Dr.  Stokes  is  of  opinion  that  the  pulse  is  a  falla- 
cious guide  in  fever,  and  that  our  attention  should  always  be  directed 
to  the  impulse  and  sounds  of  the  heart  for  guidance  either  for  the  ad- 
ministration or  withholding  of  stimulants,  and  he  then  details  the  pecu- 
liar characters  by  which  this  weakened  condition  may  be  recognised. 
I  shall  now  read  from  Dr.  Stokes's  paper  the  leading  doctrines  con- 
tained in  it : — 

''We  may  thus  arrange  the  cardiac  phenomena  obtained  in  our 
typhus  fever  : — 

''1.  Impulse  and  sounds  remaining  unaltered;  the  action  of  the 
heart  corresponding  with  that  of  the  pulse. 

"  2.  Yigorous  impulse,  with  distinct  and  proportionate  sounds,  with 
absence  of  pulse  for  many  days. 

"  3.  Diminution  of  both  sounds  of  the  heart,  with  absence  or  great 
diminution  of  the  impulse,  (fcetal  character.) 

"  4.  Diminution  of  the  first  sound,  with  cessation  or  great  feebleness 
of  the  impulse. 

"5.  Complete  extinction  of  the  first  sound,  the  second  remaining 
clear. 


250  CLINICAL  MEDICINE. 

"  6.  Predominance  of  the  first  sound,  the  second  being  extremely 
feeble. 

"  In  the  great  majority  of  cases,  however,  the  following  were  the 
phenomena  observed  : — 

"\.  Diminished  impulse. 

"2.  Diminished  first  sound,  particularly  of  the  left  cavities. 

"  With  respect  to  the  impulse  we  arrived  at  some  unexpected  results. 
In  most  cases,  considered  through  the  whole  progress,  the  diminution 
and  return  of  the  first  sound  were  accompanied  with  the  diminution  and 
return  of  the  impulse.  So  far  the  phenomena  were  what  we  might  ex- 
pect. But  in  some  instances,  at  particular  periods  of  the  case,  this  ac- 
cordance between  the  impulse  a7id  sound  did  not  exist.  In  one  case,  the 
sounds  became  distinct  before  the  impulse  returned.  In  another  the 
impulse  became  distinct  on  the  eleventh  day,  while  the  second  sound, 
greatly  preponderated.  In  a  third  case,  we  found  that  on  the  eighth  day 
the  sounds  were  not  in  proportion  to  the  impulse ;  and  on  the  tenth 
the  impulse  continued,  but  the  first  sound  was  totally  absent.  On  the 
next  day  no  impulse  could  be  felt,  yet  tlie  first  sound  was  feebly  audible. 
In  the  fourth  case,  the  impulse  on  the  twelfth  day  was  less  perceptible 
than  on  the  day  previous,  but  the  first  sound  had  more  strength." 

Dr.  Stokes  adds,  "  It  is  difficult,  or  impossible,  in  the  present  stage 
of  the  inquiry,  to  offer  any  satisfactory  explanation  of  these  apparent 
anomahes ;  but  it  seems  certain,  that  under  the  influence  of  the  typhoid 
condition,  the  heart  may  have  sufficient  force  to  give  an  impulse  with 
little  or  no  sound,  on  the  one  hand ;  and  on  the  other,  its  contractions 
may  be  accompanied  by  a  sound,  although  the  impulse  be  absent. 
Whether  we  are  to  explain  these  facts  by  referring  to  particular  states 
of  innervation  of  the  heart,  or  to  organic  alteration  of  the  muscular 
fibres  or  their  connecting  cellular  membrane,  is  still  to  be  determined." 

Farther  on  Dr.  Stokes  says,  "  That  the  cause  of  the  want  of  im- 
pulse, and  feebleness  or  cessation  of  the  first  sound,  is  a  softening  of 
the  heart,  I  have  no  doubt.  The  evidence  in  favour  of  this  opinion 
may  be  thus  stated  : — 

"I.  That  softening  of  the  heart  exists  in  typhus  fever,  as  a  lo- 
cal disease,  and  without  any  analogous  condition  of  the  muscles  of 
voluntary  life. 

"  II.  That  in  our  dissections  in  the  last  epidemic,  we  met  with  this 
softening  of  the  heart  in  cases  which  during  life  had  presented  the  phe- 
nomena in  question. 

"  III.  That  the  physical  signs  indicate  a  debility  of  the  left  ventricle 
principally,  and  it  is  this  portion  of  the  organ  which  is  most  often  al- 
tered in  consistence. 


WINE    IN    FEVER.  251 

"  IV.  Laennec  has  stated,  that  in  proportion  to  the  severity  of  the 
putrescent  phenomena,  is  the  hability  to  softening  of  the  heart.  And 
the  same  observation  is  found  to  be  true  of  the  physical  signs  now 
described. 

"  The  average  period  when  these  phenomena  appear  is  about  the  6  th 
day,  and  they  cease  about  the  14th  day.'^ 

Dr.  Stokes  considers  it  highly  probable  that  this  softened  state  of 
the  heart  depends  on  an  infiltration  through  its  muscular  structure,  of 
a  pecuhar  secretion,  identical  with,  or  closely  resembling  that  mentioned 
by  Dr.  Staberoh,  as  occurring  on  the  surface  of  the  intestinal  mucous 
membrane  in  cases  of  follicular  ulceration. 

"  This  occurring  in  the  heart  seems  to  impair  its  functions  to  a 
great  degree ;  but  the  rapid  restoration  of  the  heart  to  health  points 
out  that  the  disease  has  not  materially  impaired  its  organic  con- 
dition. 

"  FinaUy,^^  says  Dr.  S.  ''  I  would  draw  the  particular  attention  of  my 
readers  to  the  fact,  that  in  the  great  majority  of  these  cases,  the  use  of 
wine  was  followed  by  the  happiest  effects.  I  may  safely  refer  to  the 
cases  in  proof  of  this  proposition,  and  I  believe  that  in  the  diminished 
impulse,  and  in  the  feebleness  or  extinction  of  the  first  sound,  we  have 
a  new,  direct,  and  important  i?idication  for  the  use  of  wine  in  typhus 
fever/' 

I  will  now  read  the  conclusions  at  which  Dr.  Stokes  has  ar- 
rived:— 

"  I.  That  the  condition  of  the  heart  in  typhus  fever  must  be  deter- 
mined by  the  application  of  the  hand  and  stethoscope,  the  pulse  being 
an  uncertain  guide. 

"  II.  That  a  diminished  impulse,  or  a  complete  absence  of  impulse 
occurs  in  certain  cases  of  typhus  fever. 

"  III.  That  in  such  cases  we  may  observe  a  diminished  first  sound, 
or  even  an  absence  of  the  first  sound. 

*^  IV.  That  both  these  characters  may  exist  with  a  distinct  pulse. 

"  V.  That  although  in  most  cases  the  diminution  of  the  impulse  and 
first  sound  co- exists,  yet  that  impulse  may  exist  without  corresponding 
first  sound,  and  conversely  that  the  first  sound  may  be  heard  although 
unaccompanied  by  impulse. 

"  VI.  That  these  phenomena  are  most  evident  as  connected  with  the 
left  side  of  the  heart. 

"  VII.  That  when  the  impulse  or  first  sound  are  lessened  or  lost, 
the  return  to  the  healthy  character  is  observed  first  over  the  right 
cavities. 

"  VIII.  That  in  some  cases  both  sounds  are  equally  diminished. 


252  CLINICAL   MEDICINE. 

"  IX.  That  in  a  few  cases  the  first  sound  preponderates. 

"  X.  That  these  phenomena  indicate  a  debilitated  state  of  the 
heart. 

''  XI.  That  they  may  occur  at  an  early  period  of  the  disease,  and 
thus  enable  us  accordingly  to  anticipate  the  symptoms  of  general 
debility. 

"  XII.  That  the  existence  of  these  phenomena,  in  a  case  of  macu- 
lated adynamic  fever,  may  be  considered  as  pointing  out  a  softened  state 
of  the  heart. 

"  XIII.  That  this  softening  of  the  heart  seems  to  be  one  of  the 
local  lesions  of  typhus. 

'^  XIY.  That  the  diminution  or  cessation  of  impulse,  the  propor- 
tionate diminution  of  both  sounds,  or  the  preponderance  of  the  second 
sound,  are  direct  and  nearly  certain  indications  for  the  use  of  wine  in 
fever." 

Though  these  doctrines  are  entirely  new,  and  may  appear  to  some 
rather  fanciful,  yet  for  their  general  accuracy  I  can  vouch.  I  cannot 
agree,  however,  with  Dr.  Stokes,  in  attributing  the  phenomena  of  a 
debilitated  heart  to  a  softenhig  of  that  organ,  much  less  to  the  inter- 
stitial infiltration  of  a  peculiar  secretion  analogous  to  that  which 
Staberoh  states  he  has  observed  on  the  mucous  surface  of  the  intoetines 
in  dothonenterite.  On  the  contrary,  I  consider  the  heart,  in  typhus 
fever,  to  be  affected  with  debility  from  the  same  cause  which  induces  a 
debihty  of  the  voluntary  muscles,  and  of  the  bladder  and  sphincter 
ani, — that  cause  is  a  general  prostration  of  nervous  energy.  That  Dr. 
Stokes  has  seen  the  heart  softened  in  the  examination  of  subjects  that 
had  been  affected  with  typhus  fever,  I  have  no  doubt ;  but  I  would 
impute  this  condition  to  the  effect  of  putrescence,  a  process  which  it  is 
well  known  sets  in  with  great  rapidity  in  cases  where  death  has  been 
caused  by  any  mahgnant  disease.  It  seems  difficult  to  conceive  how 
the  heart  could  contract  in.  a  case  where  '^Hhe  right  cavities  were  softer 
than  natural,  admitting  the  fingers  through  their  walls  without  much 
resistance  ;  and  in  which,  in  the  muscular  structure  of  the  left  cavities, 
this  change  was  much  more  remarkable,  the  weight  of  the  finger  being 
almost  sufficient  to  penetrate  its  walls,  they  were  so  exceedingly 
softened ;  it  was  very  easily  torn,  and  the  edges  thus  separated  had  no 
longer  the  moistened  appearance,  but  seemed  as  if  quite  dry.  The 
septum  cordis  was  equally  softened ;  there  was  some  dark  fluid  blood  in 
the  right  cavities." 

But  the  fact  cannot  be  denied,  that  in  many  cases  of  typhus  the 
heart  becomes  weak,  that  this  weakness  is  manifested  by  a  decrease  in 


WINE    IN    FEVER.  253 

tlie  strength  of  its  impulse,  or  in  the  intensity  of  its  sounds,  or  a  change 
in  their  relative  loudness  and  duration — and  though  I  have  never  wit- 
nessed these  changes  without  accompanying  debility  of  the  entire  mus- 
cular system,  and  other  evidences  of  prostration,  yet  I  fully  agree 
with  Dr.  Stokes,  "  that  in  the  diminished  iin^ulse,  and  in  the  feeble- 
ness or  extinction  of  the  first  sound,  we  have  a  new,  direct,  and  im- 
portant indication  for  the  use  of  wine  in  typhus  fever ^  and  one  from 
which  the  junior  practitioner  in  particular  will  derive  the  greatest 
assistance. 

But  I  also  agree  with  Dr.  Bell,  the  distinguished  American  Editor 
of  Dr.  Stokes's  Lectures,  that  "  important  as  is  the  guide  thus  furnished 
by  the  state  of  the  heart  for  the  use  of  stimulants,  it  may  not  be  in 
the  power  of  all,  without  some  experience,  to  avail  themselves  of  it. 
The  practitioner  will,  therefore,  do  well  to  attend  to  the  following 
points,  as  directed  by  Dr.  Armstrong,  in  forming  his  opinion  of  the 
propriety  of  persevering  in  the  administration  of  wine  to  a  patient  in 
typhus  fever  : — 

"1.  If  the  tongue  become  more  dry  and  baked,  it  generally  does 
more  harm ;  if  it  become  moist,  it  generally  does  good. 

"2.  If  the  pulse  become  quicker,  it  does  harm ;  if  it  be  rendered 
slower,  it  does  good. 

"  3.  If  the  skin  become  hot  and  parched,  it  does  harm ;  if  it  become 
more  comfortably  moist,  it  does  good. 

"4.  If  the  breathing  become  more  hurried,  it  does  harm ;  if  it  be- 
come more  deep  and  slow,  it  does  good. 

"5.  If  the  patient  become  more  and  more  restless,  it  does  harm ; 
if  he  become  more  and  more  tranquil,  it  does  good." 

I  have  long  endeavoured  to  impress  on  the  minds  of  students,  the 
great  importance  of  studying  with  attention  that  stage  of  fever  in  which 
wine  and  opium  are  occasionally  the  best  remedies,  with  a  view  of 
learning  what  symptoms  indicate  their  exhibition.  In  the  commence- 
ment of  fever,  we  can  decide  with  a  good  deal  of  certainty  upon  the 
most  proper  course  of  proceeding,  but  as  the  disease  advances,  the 
symptoms  become  more  complicated,  the  indications  more  confused, 
and  the  plan  of  treatment  consequently  doubtful.  In  this  stage  of 
fever  it  is  that  we  must  rely  on  the  tact  acquired  by  previous  experience 
and  reflection,  and  must  often  depend  more  upon  a  correct  estimation 
of  the  general  state  of  the  patient,  than  upon  the  appearance  or  ab- 
sence of  any  particular  symptom.  It  is  not  my  intention  at  present  to 
do  more  than  prove  the  truth  of  this  assertion,  by  showing  that  the 
presence  of  some  symptoms,  commonly  supposed  to  contra-indicate 
the  exhibition  of  wine  and  opium,  ought  not  to  deter  the  practitioner 


254  CLINICAL  MEDICINE. 

from  their  use,  provided  that  other  circumstances  seem  urgently  to 
require  it. 

1st.  In  the  first  place,  as  to  the  tongue,  at  an  advanced  period  of 
fever,  I  have  often  derived  the  greatest  advantage  from  wine  and  opium, 
although  the  tongue  was  dry — the  colour  of  old  mahogany  or  else 
coated  with  a  yellowish  brown  fur,  and  protruded  with  difficulty,  while 
the  teeth  and  gums  were  covered  with  sordes.  Wine  and  porter  in 
moderate  quantities  seem  generally  to  agree  better  with  this  tongue  than 
opium;  in  some  cases,  however,  the  latter  is  indispensable. 

Eor  fear  of  misleading  you,  I  must  again  remark,  I  by  no  means 
wish  to  assert  that  such  a  tongue  uniformly,  or  even  frequently 
indicates  the  use  of  these  medicines ;  on  the  contrary,  this  state  of 
tongue  and  mouth  will  often  be  observed  at  a  time  when  leeches  and 
antiphlogistic  treatment  are  required.  Let  it  be  clearly  understood, 
however,  that  at  an  advanced  period  of  fever,  this  state  of  the  tongue 
may  exist,  and  yet  wine  and  opium  may  be  given  boldly,  provided, 
as  I  have  said  before,  the  general  state  of  the  patient  seems  to  re- 
quire it. 

2ndly.  The  observations  I  have  made  concerning  the  tongue  are 
applicable  to  suffusion  of  the  eyes.  The  eyes  may  be  heavy,  a  little 
red,  very  much  suffused,  and  may  have  the  singular  expression  of 
watchfulness,  combined  with  great  redness  of  the  conjunctiva,  which  is 
termed  a  ferrety  eye,  and  yet  wine  or  opium  may  be  the  only  remedy 
capable  of  saving  the  patienf  s  life.  It  should  always  be  borne  in  mind, 
that  the  want  of  sleep  tends  to  make  the  eye  red,  and  that  this  condi- 
tion is  often,  when  it  occurs  in  maculated  typhus,  analogous  to  the 
similar  appearance  of  the  eye  winch  is  observed  both  in  measles  and 
scarlatina,  in  which  diseases  it  is  merely  a  part  of  the  general  erythema, 
and  does  not  contra-indicate  the  use  of  wine  and  opium  if  other  cir- 
cumstances call  for  their  exhibition. 

3rdly.  A  hot  and  dry  skin  does  not  necessarily  contra-indicate  the 
exhibition  of  wine  and  opium,  particularly  where  there  is  at  the  same 
time  a  tendency  to  coldness  of  the  extremities. 

4thly.  The  presence  or  absence  of  delirium  must  always  excite  our 
attention,  when  the  question  of  giving  wine  or  opium  arises.  I  believe 
that  these  medicines  are  never  applicable  when  the  delirium  is  violent 
and  continuous,  but  the  patient  may  rave  a  great  deal,  particularly  at 
night ;  he  may  mutter  and  speak  to  himself ;  he  may  point  to  various 
imaginary  appearances,  and  may  fancy  himself  surrounded  by  persons 
or  things  which  have  no  real  existence ;  he  may  be  restless  and  irritable, 
constantly  endeavouring  to  leave  his  bed  for  the  purpose  of  walking 
about  the  room,  or  sitting  at  the  fire ;  and  yet  he  may  be  in  a  state 


WINE    IN    FEVER.  255 

urgently  demanding  wine  and  opium.  On  a  more  accurate  examina- 
tion, we  find  that  his  delusions  are  not  so  strong  as  to  leave  no  room 
for  the  exercise  of  his  reason.  When  spoken  to  emphatically,  he  an- 
swers in  some  cases  incoherently,  but  in  others,  with  perfect  precision 
and  presence  of  mind,  and  does  not,  for  some  minutes,  relapse  into 
his  former  wanderings.  This  state  of  mind  is  usually  accompanied  by 
an  almost  total  want  of  sleep,  and  in  many,  by  a  great  anxiety  about 
their  illness.  To  procure  sleep,  as  has  been  well  remarked  by  Latham, 
in  a  late  number  of  the  Medical  Gazette,  is  here  one  great  object,  and 
this  can  only  be  done  by  means  of  wine  and  narcotics.  In  some  the 
mental  aberration  is  scarcely  perceptible,  and  they  have  all  the  cha- 
racters of  great  excitement  of  the  nervous  system,  without  any  actual 
raving  or  delirium.  There  is  general  tremor  and  subsultus.  The 
tongue  is  tremulous  when  protruded,  or  when  moved  in  speaking, 
and  consequently  the  articulation  is  uncertain  and  interrupted,  while  in 
general  manner  and  mode  of  answering  questions,  the  patient  strongly 
resembles  a  person  affected  with  delirium  tremens."^  This  group  of 
symptoms  is  likewise  accompanied  by  want  of  sleep,  and  best  treated 
with  wine  and  opium. 

5thly.  The  appearance  of  the  face  has  been  much  relied  on  by  some, 
as  capable  of  guiding  us  in  forming  our  decision.  Heat  of  head  and 
face,  redness  of  the  cheeks,  and  strong  pulsation  of  the  carotids,  are 
well  known  as  contra-indicating  wine  or  opium ;  but  in  the  advanced 
stages  of  fever,  the  face,  like  the  eye,  may  be  suffused,  it  may  be  seen 
occasionally  flushed ;  and  when  flushed,  it  may  be  hot,  and  yet  wine 
and  opium  may,  nevertheless,  be  our  only  resource. 

6thly.  Headache,  when  violent,  is  at  any  period  of  fever  a  decisive 
circumstance.  Sleep  cannot  be  obtained  wliile  the  pain  is  unmitigated, 
and  we  must,  therefore,  attempt  to  conquer  it  by  the  most  active  treat- 
ment, by  local  applications  to  the  head,  by  depletion  from  the  vascular 
system,  and  by  purgatives.  Sometimes,  however,  these  means  fail,  and 
the  physician  feels  that  he  cannot  pursue  tliis  mode  of  treatment  any 
further.  Under  such  circumstances,  a  dose  of  opium  boldly  exhibited 
will  occasionally  succeed  in  procuring  sleep,  from  which  the  patient 
awakes  nearly  free  from  headache.  Before  having  recourse  to  this  re- 
medy, the  effects  of  a  blister  to  the  nape  of  the  neck  ought  to  be  tried. 
In  the  more  advanced  stages  of  fever,  the  headache,  or  rather  the 
heaviness  felt  in  the  head,  is  something  very  different  from  the  throb- 
bing, acute  headache  just  spoken  of,  and  constitutes  no  contra-indica- 
tion  to  the  use  of  wine  and  opium. 

•  It  is  in  these  particular  forms  of  fever  that  I  have  discovered  the  great  iitility  of  tartar 
emetic  and  opium  ;  see  last  lecture. 


256  CLINICAL   MEDICINE. 

7tlilj.  The  state  of  the  pulse  requires  to  be  duly  considered.  Its 
frequency  is  not  of  much  importance,  for  I  have  seen  wine  and  opium 
prove  liighly  serviceable  in  all  its  varieties,  from  70  to  130,  or  even 
upwards.  No  one  would  ever  think  of  exhibiting  these  remedies  when 
the  pulse  is  strong,  and  more  particularly  when  it  is  strong  and  hard ; 
but  the  case  is  otherwise  when  it  possesses  only  a  certain  degree  of 
hardness,  and  is  at  the  same  time  small  and  thrilling,  not  resisting  com- 
pression with  the  force  the  sensation  of  its  hardness  leads  us  to  expect. 

Such  are  the  chief  observations  I  have  made  on  the  particular  cir- 
cumstances and  symptoms  supposed  capable  of  throwing  light  on  this 
important  practical  question.  They  may  serve  to  prevent  the  student 
from  being  misled  by  rules  of  practice  dogmatically  deduced  from  the 
observations  of  any  single  symptom,  and  may  lead  him  to  turn  his  at- 
tention more  accurately  to  the  previous  progress  of  the  fever,  and  the 
general  state  of  the  patient.  It  is  almost  superfluous  to  add,  that  when 
any  doubts  exist  concerning  the  propriety  of  giving  wine  and  opium 
in  fever,  they  should  not  be  tried  unless  their  effects  be  carefully  watched 
by  the  physician  himself. 

Permit  me  next  to  call  your  attention  to  some  of  the  sequelae  of  fever, 
and  first  to  some  points  connected  with  sudden  and  violent  delirium 
succeeding  maculated  typhus  fever.  It  may  be  doubted,  whether  any 
writer  has  illustrated  with  sufficient  details,  the  fact,  that  delirium  of  a 
most  violent  and  dangerous  description,  sometimes  suddenly  supervenes 
in  patients,  who,  to  all  appearance,  have  passed  favourably  through  the 
various  stages  of  maculated  fever.  I  published  on  a  former  occasion, 
the  case  of  a  student  in  Trinity  CoUege,  who  was  thus  attacked  on  the 
eighteenth  day,  at  a  time  when  he  seemed  to  have  passed  the  crisis  fa- 
vourably, his  pulse  having  fallen  to  60,  and  all  other  symptoms  of  fever 
having  disappeared ;  since  that  observation  was  made,  I  have  seen  so 
many  cases  of  a  similar  description,  that  I  think  it  right  to  impart  what- 
ever additional  experience  has  taught  me  concerning  the  history  and 
treatment  of  this  singular  species  of  delirium.  It  will  appear  evident, 
from  the  nature  of  the  means  successfully  employed  in  treating  this  af- 
fection, that  it  has  little  or  no  affinity  to  the  delirium  which,  in  the  first 
stages  of  fever,  so  often  accompanies  true  inflammation  or  congestion  of 
the  brain,  but  is  rather  allied  to  delirium  tremens,  delirium  traumaticum, 
and  acute  puerperal  madness.  As  in  each  of  these  the  delirium  is  pre- 
ceded by  the  operation  of  some  cause,  which  acts  unfavourably  on  the 
nervous  system ;  so  in  the  delirium  we  are  now  about  to  consider,  the 
pre-existence  of  fever  may  be  assumed  to  act  in  a  similar  manner. 
Neither   does  maculated  fever  seem  more  inadequate  to  produce  so 


DELIllIUM    AS    ONE    OF   THE    SEQTJEL.i5    OF    FEVER.  257 

serious  an  effect,  than  the  act  of  parturition,  tlie  presence  of  a  wound  or 
fracture,  or  the  long-continued  abuse  of  intoxicating  liquors;  for  no 
severe  typhus  fever  ever  runs  its  course,  without  bearing  heavily  on  the 
nervous  system.  The  facts  I  am  to  relate,  ought  to  make  physicians 
extremely  cautious  about  pronouncing  fever  patients  out  of  danger ;  for 
even  after  a  crisis,  occurring  in  due  time,  and  apparently  the  most  satis- 
factory and  complete,  delirium  may  suddenly  arise,  and  may  place  the 
patient  in  the  greatest  peril,  the  physician  having,  perhaps,  taken  his 
leave,  in  the  full  assurance,  that  his  visits  were  no  longer  necessary. 

Four  years  ago  I  attended,  with  the  late  Mr.  King,  a  gentleman 
in  Grafton-street,  who  had  fever  without  any  remarkable  symptom,  or 
anything  that  required  the  adoption  of  active  measures.  He  had  maculae, 
it  is  true,  but  the  patient  was  young,  and  went  through  the  disease  fa- 
vourably ;  on  the  sixteenth  day  his  pulse  had  fallen  to  sixty,  and  all 
danger  seemed  over.  He  had  no  thirst ;  his  tongue  was  moist ;  eyes 
clear ;  and  not  the  slightest  headache,  or  appearance  of  cerebral  deter- 
mination :  in  fact,  when  I  visited  him  on  the  morning  of  the  seventh 
day,  every  thing  betokened  a  speedy  recovery.  I  must  observe,  how- 
ever, that  in  this,  as  well  as  in  most  cases  of  the  kind  I  have  witnessed, 
there  was  a  certain  degree  of  nervous  excitement  present,  tending  to 
produce  want  of  sleep,  and  consequently  on  leaving  him  at  my  evening 
visit,  I  directed  the  nurse  to  give  him  an  opiate  draught.  This  was  un- 
fortunately omitted ;  the  young  gentleman  became  gradually  more  rest- 
less and  agitated,  began  to  rave,  and  was  found  by  Mr.  King,  next 
morning,  in  a  state  of  high  delirium.  His  pulse  was  still  rather  slow^, 
not  more  than  sixty  in  a  minute ;  his  skin  was  cold ;  his  countenance 
collapsed;  and  he  had  been  during  the  night  wholly  sleepless.  We  had 
great  difficulty  in  managing  this  patient ;  and  it  was  only  by  means  of 
great  attention,  stuping  his  legs,  a  nutritious  diet,  wine,  and  black  drop — r 
exhibited  freely  and  repeatedly,  that  his  life  was  saved. 

Anotlier  case  of  the  same  kind,  and  calculated  to  excite  great  interest, 
was  that  of  a  pupil  of  the  Meath  Hospital.  This  gentleman  was  attacked 
with  the  prevailing  fever,  and  like  most  patients,  exhibited  maculse  about 
the  fifth  day.  There  was,  how^ever,  nothing  very  remarkable  in  his  disease, 
no  symptoms  of  anomalous  character,  or  of  a  severity  requiring  very  active 
measures.  When  first  attacked,  he  felt  rather  nervous;  but  this  was 
very  little  to  be  wondered  at  in  a  person  W'ho  had  been  studying  intensely 
for  a  considerable  time. 

At  a  very  early  period  he  exhibited  a  tendency  to  tremors  and  sub- 
sultus  tendinum;  but  all  his  other  symptoms  w^ere  mild,  and  by  strict 
attention,  and  the  kind  care  of  his  fellow-students,  he  went  through  the 
disease  favourably,  and  appeared  quite  free  from  danger  on  the  sixteenth 

VOL.  I.  17 


258  CLINICAL   MEDICINE. 

day.  On  the  seventeenth  day  I  found  him,  at  my  morning  visit,  in  a 
very  promising  condition,  his  pulse  down  to  60  ;  his  tongue  moist ;  his 
skin  of  a  natural  temperature ;  and  his  eye  clear,  and  nothing  present 
but  a  certain  degree  of  nervous  excitement.  To  counteract  this  ten- 
dency the  late  Dr.  M'Dowel  and  I  had  found  it  necessaiy  to  give  him 
every  night  an  enema  containing  twenty-five  drops  of  tincture  of  opium. 
Unfortunately  this  was  omitted  for  one  or  two  nights  about  this  period. 
The  fever  resolved  itself ;  but  resolved  itself  during  the  period  of  sleep- 
lessness, and  a  certain  degree  of  nervous  excitement.  I  saw  him  on  the 
morning  of  the  eighteenth;  I  thought  there  was  a  good  deal  of  anxiety 
and  quickness  of  manner  about  him,  with  some  slight  increase  in  the 
muscular  tremors.  I  therefore  wrote  to  Dr.  M'Dowel,  and  begged  him 
to  see  that  he  took  his  opiate  that  night.  Before  this  was  done,  he 
grew  much  worse ;  in  the  evening  he  became  highly  excited,  then  quite 
delirious,  and  towards  morning  it  was  necessary  to  call  in  the  assistance 
of  three  or  four  persons  to  keep  him  in  bed.  Dr.  M^Dowel  continued 
to  attend  him  with  great  care  and  skill,  and  had  sufiicient  influence  over 
him  to  make  him  swallow  the  requisite  medicines,  which  no  one  else 
could.  Opiates  were  at  first  tried,  but  failed ;  we  then  commenced  with  the 
free  exhibition  of  tartar  emetic,  and  extract  of  belladonna ;  in  the  course 
of  twenty-four  hours  he  took  five  or  six  grains  of  the  latter ;  we  after- 
wards omitted  the  tartar  emetic,  and  substituted  black  drop  in  its  place : 
this  succeeded,  and  after  a  violent  attack  of  delirium,  which  lasted  for 
thirty-eight  or  forty  hours,  he  fell  into  a  deep  sleep,  from  which  he 
awoke  refreshed  and  rational.  It  was  necessary,  however,  to  repeat  the 
narcotics  for  several  nights,  and  they  were  not  omitted  until  his  conva- 
lescence became  so  confirmed,  as  to  remove  any  apprehension  of  a  re- 
lapse. 

Here  are  two  cases  in  which  the  disease  declines,  and  the  patient  is 
regarded  as  nearly  convalescent,  when  suddenly  cerebral  symptoms  of  a 
most  alarming  character  manifest  themselves.  The  fever  subsides,  but 
with  nervous  excitement  and  insomnia,  circumstances  which  have  been 
long  observed  as  characteristic  of  an  imperfect  crisis.  The  point,  how- 
ever, to  which  I  wish  to  direct  attention  is,  that  a  person  not  thoroughly 
acquainted  with  the  nature  of  this  affection  might  be  led  into  a  very 
important  error.  He  might,  perhaps,  suppose  this  to  be  inflammatory 
excitement,  to  be  treated  by  leeches,  cold  to  the  head,  and  other 
antiphlogistic  measures.  In  the  first  case,  indeed,  the  symptoms  were 
so  violent,  that  I  advised  leeching ;  but  Dr.  M^Dowel  did  not  apply 
them,  and  perhaps  it  was  well  that  he  did  not.  I  do  not  mean  to  say, 
that  leeches  and  the  antiphlogistic  treatment  are  never  indicated  in  the 
delirium  which  occurs  at  an  advanced  period  of  maculated  fever,  or  in 


i 


DELIRIUM    AS    ONE    OP   THE    SEQUELAE    OF    FEVER.  259 

that  which  follows  the  stage  in  which  the  pulse  falls  to  the  natural 
standard^  and  thirst  ceases,  and  the  skin  grows  cool.  Such  an  asser- 
tion would  lead,  in  some  instances  to  an  injudicious  and  even  dangerous 
method  of  treatment ;  for  cases  do  occur  where,  under  these  circum- 
stances, topical  antiphlogistic  measures  are  absolutely  called  for.  My 
object  in  making  these  remarks  is,  to  point  out,  not  the  rule,  but  the 
exceptions,  the  numerous  exceptions  to  the  method  of  treatment  usually 
employed.  In  the  delirium  I  am  now  describing,  the  feet  and  legs 
must  be  constantly  stuped,  the  head  must  be  diligently  spunged  with 
warm  water  and  vinegar,  the  bowels  relieved  by  injections,  while  opium 
is  exhibited  by  the  mouth  or  in  lavements  ;  where  there  is  warmth  of 
the  scalp,  and  the  temporal  arteries  full,  leeches  are  required,  but  where 
the  scalp  is  not  hotter  than  natural,  they  would  prove  hurtful ;  in  a 
state  of  coUapse,  wine  may  be  necessary ;  blisters  to  the  nape  or  head 
seem  to  increase  the  delirium.  When  leeches  are  indicated,  their  good 
effects  are  much  enhanced  by  combining  tartar  emetic  with  the  opium, 
provided  no  diarrhoea  nor  other  symptom  of  abdominal  irritation  can  be 
detected. 

The  next  case  is  even  more  remarkable  than  the  preceding,  for  the 
delirium  came  on  quite  suddenly  and  without  any  premonitory  symptom, 
and  did  not  commence  for  several  days  after  the  fever  had  entirely 
ceased,  which  it  did  about  the  seventeenth  day ;  neither  was  the  ter- 
mination, in  this  instance,  rendered  suspicious  by  any  previous  want  of 
sleep. 

Mr. was   attended  by  Doctor   Brereton,   who   found  him 

labouring  under  the  usual  symptoms  of  fever,  which  commenced  about 
the  27th  of  January,  1835.  He  was  a  young  man  of  excellent  con- 
stitution, and  temperate,  active  habits  :  soon  after  the  commencement 
of  the  disease,  some  bronchitic  symptoms  appeared,  and  at  the  usual 
time  the  maculated  eruption  was  observed.  Nothing  remarkable  oc- 
curred, until  towards  the  fourteenth  day,  when  a  notable  and  steady 
improvement  commenced,  and  consequently  I  left  off  my  attendance, 
having  been  called  in  about  the  seventh  day  of  the  disease.  As  the 
patient's  constitution  was  sound,  liis  friends  were  not  Hkely  to  permit 
any  error  of  diet,  and  I  did  not  anticipate  a  relapse,  especially  as  there 
had  been  no  serious  affection  of  the  brain,  chest,  or  bowels  during  the 
course  of  the  fever.  I  left  him  cool,  cheerful,  and  self-possessed,  his 
pulse  regular,  about  sixty  in  the  minute,  and  head  entirely  free  from 
pain  or  flushing ;  his  tongue  had  become  clean ;  thirst  gone,  and  appe- 
tite returning.  All  these  particulars  were  of  the  most  encouraging 
description,  and  were  not  counterbalanced  by  any  symptom  indicative 
of  the  fast  approacliing  danger.     On  the  following  day,  the  eighteenth 


^60  CLINICAL   MEDICINE. 

from  the  beginning  of  his  fever,  I  was  again  sent  for  in  haste,  and 
found  that  the  patient  had  become  suddenly  and  outrageously  delirious 
during  the  night,  an  occurrence  which  seemed  the  more  surprising,  as 
no  other  symptom  existed  denoting  a  return  of  fever.  This  gentleman's 
life  was  saved  with  great  difficulty,  for  the  delirium  continued  several 
days,  and  was  at  last  only  appeased  by  considerable  doses  of  tartar 
emetic,  combined  with  musk  and  opium. 

There  is  one  fact  connected  with  the  history  of  fever,  which  should 
never  be  forgotten  by  those  who  are  occupied  in  its  treatment :  I  allude 
here  to  the  occurrence  of  sudden  accidents,  or  the  supervention  of  other 
diseases,  producing  a  material  alteration  in  the  circumstances  of  the 
case,  and  leading  to  new  and  more  alarming  dangers.  You  should  not 
divest  yourselves  of  all  further  anxiety  for  the  patient,  or  relax  in  your 
attentions,  because  the  fever  has  exhibited  a  tendency  to  decline,  and  a 
favourable  crisis  has  taken  place :  crisis  may  occur,  and  convalescence 
may  be  estabhshed,  and  yet  the  patient  may  relapse,  or  he  may  be  struck 
down  again  by  the  unexpected  incursion  of  a  new  and  dangerous  ma- 
lady, or  he  may  expire  suddenly  in  the  course  of  a  few  minutes.  The 
functions  of  the  brain  and  heart  may  suddenly  give  way,  and  death  may 
take  place  unexpectedly  and  at  once.  Thus  it  not  unfrequently  hap- 
pens that  a  patient  during  Ms  convalescence  falls  into  a  state  of  syncope^ 
from  remaining  too  long  in  the  erect  posture,  and  if  assistance  be  not 
promptly  afforded,  life  is  speedily  extinguished.  In  the  state  of  debi- 
lity which  follows  acute  and  exhausting  diseases,  and  where  the  patient 
is  very  liable  to  syncope,  the  most  assiduous  attention  is  required. 
During  the  epidemic  of  1826,  death  took  place  under  such  circum- 
stances in  five  or  six  instances,  and  the  convalescents  lost  their  lives 
from  incautiously  sitting  up  or  walking  about  the  room  too  long,  or 
attempting  to  reach  the  night-chair  without  assistance.  There  are 
many  other  causes  capable  of  producing  a  sudden  and  alarming  change 
in  the  state  of  convalescents  from  fever.  One  of  the  most  obvious  of 
these  is  error  or  excess  in  diet,  which  is  apt  to  bring  on  a  return  of  the 
fever  in  an  aggravated  form,  accompanied  by  symptoms  of  gastro-enteric 
inflammation,  and  sometimes  terminating  fatally  in  forty-eight  hours. 

I  shall  now  proceed  to  lay  before  you  a  sketch  of  a  very  important 
form  of  disease  which  attacks  convalescents  from  fever,  and  runs  a 
course  of  remarkable  intensity  and  rapidity.  I  am  not  aware  that  this 
form  of  disease  has  been  described  by  pathological  writers  :  the  nearest 
approach  to  a  description  of  it  is  an  account  of  the  swelled  leg  which 
occurs  after  fever,  given  by  a  Glasgow  physician.  Dr.  Stokes  and  I 
have  given  a  description  of  a  swelled  leg  after  fever,  as  observed  dur- 
ing the  epidemic  of  1826,  but  the  important  and  fatal  form  of  the  dis- 


SEQUEL.E    OF    FEVER.  261 

ease  wliicli  I  am  about  to  describe,  did  not  come  under  my  notice  until 
within  a  more  recent  period. 

Before  the  commencement  of  the  present  session,  a  fine  young  woman, 
aged  24,  previously  healthy  and  robust,  was  admitted  into  our  fever 
ward.  She  was  admitted  on  the  26th  of  September,  having  been  at 
that  time  eight  days  ill,  and  labouring  cliiefly  under  gastric  and  cerebral 
symptoms.  Her  treatment  consisted  in  the  application  of  leeches  to 
the  epigastrium  and  head,  cooling  drinks,  and  blue  pill  combined  with 
James's  powder.  Under  the  use  of  these  and  other  appropriate  remedies, 
the  fever  declined,  and  on  the  1st  of  October  the  cerebral  and  gastric 
symptoms  had  disappeared,  and  the  patient  complained  merely  of  a 
shght  degree  of  feverishness.  On  the  2d  of  October  she  was  seized 
with  rigors  and  horripilation,  followed  by  intense  pain  of  the  left 
mamma,  accompanied  by  numbness  and  loss  of  power  of  the  corres- 
ponding arm.  She  was  leeched  with  some  relief,  but  passed  a  sleepless 
night,  and  next  day  an  oblong  patch  of  redness  was  seen  extending  up- 
wards from  the  nipple ;  the  pain  was  still  violent,  and  she  could  not 
bear  the  slightest  touch  on  the  affected  parts.  The  breast  was  leeched 
again,  and  fomented  assiduously  during  the  day.  On  the  4th  the  ery- 
sipelas was  spreading,  and  the  pain  was  still  agonising.  She  screamed 
out  whenever  it  was  touched,  and  could  not  bear  even  the  weight  of  her 
dress  or  covering.  On  examining  the  breast,  no  enlargement  or  hard- 
ness could  be  observed ;  there  was  no  remarkable  heat  or  tension,  and 
with  the  exception  of  a  shght  erysipelatous  redness,  and  pain  rivalling 
that  of  tic  douloureux  in  severity,  there  was  nothing  to  indicate  the  pre- 
sence of  the  disease.     The  left  arm  continued  numb  and  powerless. 

This  state  of  things  was  accompanied  by  remarkable  increase  of  fever, 
as  manifested  by  foul  tongue,  accelerated  pulse,  and  sleepless  nights. 
She  now  began  to  complain  of  dull  pain  in  the  calf  of  the  right  leg, 
aggravated  by  pressure  or  motion,  but  not  attended  with  any  apparent 
increase  of  heat,  swelling,  or  induration.  On  the  5th  she  is  reported  to 
have  passed  a  sleepless  night,  although  the  watery  extract  of  opium  had 
been  administered  freely  on  the  preceding  day  and  evening ;  the  erysi- 
])elatous  redness  had  extended  nearly  as  high  as  the  clavicle,  and  the 
affected  parts  had  now  begun  to  swell  considerably.  On  the  6th  she  is 
stated  to  have  had  some  sleep,  and  the  erysipelas  was  extending,  in  some 
parts  covered  with  vesicles.  She  again  complained  of  cramps  in  the 
right  leg,  and  on  making  an  examination  we  found  considerable  tender^ 
ness  on  making  deep  pressure,  but  no  external  indication  of  disease. 
Her  debility  was  increasing,  accompanied  by  a  tendency  to  looseness  of 
bowels,  for  which  she  was  ordered  enemata  of  sulphate  of  quina  and 
laudanum.     On  the  following  night  slie  was  attacked  with  intense  pain 


262  CLINICAL   MEDICINE. 

in  the  leg,  accompanied  bj  exquisite  tenderness  to  the  touchy  but  no  red- 
ness, sweUing,  or  increase  of  temperature.  The  erysipelatous  affection 
of  the  breast  had  now  become  pale,  and  ceased  to  spread.  The  enemata 
were  continued,  the  parts  dressed  with  mercurial  ointment  and  extract 
of  belladonna,  and  wine  freely  allowed. 

She  passed  the  night  in  great  agony  from  the  intense  pain  in  the  leg, 
and  complained  of  frequently  recurring  rigors  followed  by  perspirations. 
She  also  stated  that  for  the  last  two  or  tliree  days  she  had  experienced 
repeated  attacks  of  tremor  in  the  affected  limb ;  one  of  these  tremors 
attacked  the  limb  on  the  night  of  the  8th,  and  continued  for  three  or 
four  hours,  terminating  in  copious  general  perspiration.  These  increased 
on  the  following  day,  attended  with  increase  of  fever,  thirst,  and  debility, 
and  the  pain  in  the  leg  continued  with  unabated  violence.  It  is  worthy 
of  remark,  that  at  this  time  there  was  no  erysipelatous  redness  or  disco- 
loration of  the  affected  limb,  and  scarcely  any  swelling.  On  the  9th, 
she  is  reported  to  have  passed  the  night  screaming  and  sleepless,  she 
vomited  three  or  four  times,  complained  of  intense  pain  in  the  abdomen, 
and  had  a  violent  rigor  which  continued  from  one  o^clock  to  six  in  the 
morning,  followed  by  profuse  perspiration.  The  right  leg  continued  ex- 
quisitely painful  as  before,  became  somewhat  swollen,  and  its  veins  ap- 
peared more  prominent  than  natural,  but  there  was  no  discoloration  of 
the  integuments.  Both  arms  were  now  painful  on  motion,  and  the  left 
leg  became  painful  and  tender  on  pressure.  Under  this  complication  she 
sank  rapidly,  and  died  at  three  o'clock  in  the  afternoon. 

On  dissection,  purulent  matter  was  found  under  the  integuments 
covering  the  kft  breast,  but  the  gland  itself  appeared  healthy.  There 
was  no  vascularity  nor  other  traces  of  peritoneal  inflammation,  and  the 
abdominal  viscera  were  healthy.  The  right  leg  was  infiltrated ;  its  veins 
were  pervious  and  elastic,  but  their  internal  coat  exhibited  a  rose-coloured 
tinge. 

Here,  then,  we  have  a  very  remarkable  and  formidable  train  of  symp- 
toms, arising  without  any  obvious  cause,  running  a  rapid  and  fatal  course, 
and  exhibiting  a  character  of  singular  intractability.  From  all  that  we 
had  previously  seen  or  heard,  this  young  woman's  constitution  was  robust 
and  healthy,  her  fever  had  been  treated  successfully,  and  she  appeared  to 
be  getting  over  it  without  any  sinister  accident,  or  any  compHcation 
capable  of  disturbing  her  convalescence ;  yet  at  this  period  she  is  attacked 
with  fever  of  a  new  type,  accompanied  by  local  affections  of  the  breast 
and  extremities,  which  run  a  rapidly  fatal  course,  and  exhibit  phenomena 
of  a  new  and  extraordinary  character.  She  is  first  attacked  with  erysi- 
pelas of  the  left  mamma,  accompanied  by  pain  and  loss  of  power  of  the 
corresponding  arm ;  then  she  gets  exquisite  pain  of  the  right  leg,  and 


SEQUELS    OF    FEVER.  263 

then  of  the  left  leg  and  right  arm ;  in  fact  the  whole  four  extremities  are 
more  or  less  imphcated. 

Now  by  what  name  should  we  designate  this  affection,  or  what  would 
be  the  most  appropriate  term  to  apply  to  it  ?  Was  it  phlebitis,  or  ery- 
sipelas, or  plilegmasia  dolens  ?  The  affection  of  the  mamma  certainly 
resembled  erysipelas,  but  differed  from  it  in  the  agonising  character  of 
the  pain,  and  I  have  already  observed  that  in  the  legs  or  arms  there  was 
no  appearance  of  redness  or  discoloration.  That  it  was  pure  phlebitis  I 
think  we  are  not  authorised  in  concluding,  from  the  phenomena  observed 
on  dissection.  There  was  no  pus  in  the  veins  (an  occurrence  which 
might  naturally  be  expected  from  the  acute  character  of  the  disease,)  no 
thickening  or  induration,  the  coats  of  the  veins  were  elastic,  and  to  all 
appearance  healthy,  with  the  exception  of  a  rose-coloured  tinge.  Now 
considering  the  previous  state  of  the  woman's  system,  I  do  not  think 
that  we  can  conclude  as  to  the  existence  of  pure  phlebitis  on  such 
slight  grounds,  or  say  that  the  whole  group  of  symptoms  which 
characterised  the  secondary  attack  depended  solely  on  inflammation  of 
the  veins. 

The  disease  of  which  I  speak  simulated  in  many  points  plilegmasia 
dolens,  but  differed  from  it  in  the  phenomena  observed  in  the  breast,  as 
well  as  its  more  general  diffusion,  and  the  absence  of  that  peculiar  white- 
ness of  the  affected  limb  which  characterises  the  latter  affection.  It  ap- 
pears to  be  a  form  of  disease  resulting  from  the  generation  of  a  morbid 
poison  in  the  system,  and  manifesting  itself  in  diffuse  subcutaneous  in- 
flammation of  a  low  and  cachectic  nature,  affecting  primarily  the  skin  and 
subcutaneous  areolar  tissue,  and  afterwards  involving  all  the  subjacent 
parts  more  or  less  according  to  their  different  susceptibihties.  It  was 
accompanied  from  the  commencement  by  increased  irritability  of  the 
muscular  and  cutaneous  nerves ;  indeed,  in  the  case  just  detailed,  the 
nerves  appear  to  be  the  parts  primarily  affected.  Another  remarkable 
circumstance  connected  with  this  case  is  the  loss  of  power,  observed  in 
the  affected  limbs.  In  all  cases  where  a  severe  and  painful  affection  of 
the  nerves  is  present,  you  have  more  or  less  loss  of  power,  but  as  far  as 
my  observation  has  gone,  there  appears  to  be  a  difference  in  the  derange- 
ment of  muscular  motion  connected  with  painful  affections  of  large  ner- 
vous trunks,  and  that  which  accompanies  an  affection  of  the  terminating 
fibrils  or  nervous  extremities.  In  the  latter  case  the  degree  of  paralysis 
is  always  more  considerable ;  of  this,  phlegmasia  dolens  affords  a  good 
illustration.  In  tliis  disease  the  extremities  of  the  nerves  are  chiefly 
affected,  and  the  loss  of  power  is  always  greater  than  when  a  large  ner- 
vous trunk  is  affected,  as  for  instance  in  sciatica.  In  the  latter  affection 
the  pain  is  often  extremely  violent,  but  the  motion  of  the  limb  is  never 


264  CLINICAL   MEDICINE. 

SO  much  impeded  as  it  is  when  the  nervous  extremities  are  the  parts 
chiefly  engaged. 

You  perceive,  then,  that  the  afi'ection  which  I  have  just  described 
consists  in  the  development  of  low,  malignant,  and  irregular  inflam- 
matory affections  in  various  parts  of  the  body,  but  particularly  in  the 
extremities,  commencing  probably  in  the  subcutaneous  areolar  tissue, 
but  subsequently  extending  to  all  the  neighbouring  parts,  and  exhibit- 
ing many  of  the  characters  of  those  inflammations  which  result  from 
the  presence  of  an  animal  poison  in  the  system.  A  peculiar  feature  of 
this  affection,  also,  is  the  intense  neuralgic  pain  which  accompanied  it, 
and  I  think  it  might  with  some  propriety  be  designated  as  neuralgic 
diffuse  inflammation  after  fever.  It  is  accompanied  by  fever  of  a  pe- 
culiar type,  ushered  in  by  rigors,  and  characterised  by  remarkable 
derangement  of  the  digestive  canal,  debility,  and  sleeplessness.  A  point 
also  which  deserves  notice  in  this  case  was,  the  recurrent  rigors  and 
perspirations,  marking  the  occurrence  of  new  and  additional  mischief, 
and  indicating  the  malignant  and  intractable  nature  of  the  disease. 

One  word  as  to  the  connection  of  this  disease  with  phlebitis.  Some 
pathologists  are  of  opinion  that  phlegmasia  dolens  and  swelled  leg  after 
fever  are  nothing  more  than  modifications  of  phlebitis.  I  cannot,  I 
■must  confess,  agree  with  this  opinion,  nor  am  I  prepared  to  admit  that 
the  symptoms  in  the  foregoing  case  w^ere  referable  to  mere  inflammation 
of  the  veins.  I  do  not  deny  that  the  veins  may  be  affected,  but  phlebitis 
is  not  the  first  link  in  the  morbid  chaiii,  and  is  itself  merely  a  conse- 
quence of  the  same  unknown  cause  which  determined  the  inflammation 
of  other  tissues.  I  beg  leave  to  observ^e  here,  that  the  affection  I  have 
just  described  seems  like  others  capable  of  existing  in  very  different 
degrees.  Thus,  I  have  seen  some  instances  in  which  there  was  no  other 
symptom  but  severe  pain  of  the  extremities,  generally  about  the  calves 
of  the  legs,  and  which  was  reheved  by  warm  fomentations  and  mild 
aperients.  Again,  I  have  seen,  in  addition  to  this  symptom,  swelHng  and 
tenderness  of  the  legs,  wliich,  however,  generally  yielded  to  leeching 
and  other  appropriate  means.  Probably  we  are  authorised  from  this 
and  other  facts  in  concluding,  that  the  disease  is  not  always  of  a  ma- 
lignant and  fatal  character,  and  that  there  are  at  least  certain  forms 
of  it  amenable  even  to  simple  and  ordinary  treatment :  you  should,  how- 
ever, be  always  on  your  guard  when  patients  recovering  from  fever  are 
attacked  with  pain,  in  the  lower  extremities  particularly,  as  this  symp- 
tom not  unfrequently  ushers  in  a  serious  and  alarming  disease. 

The  next  case  of  this  disease  observed  in  our  wards,  occurred  also  in 
a  young  woman,  named  Dillon,  aged  23,  and  apparently  of  good  con- 
Btitution.     She  was  admitted  into  the  fever  ward  on  the  2d  of  Septera- 


seciup:l.e  of  fever.  265 

ber,  being  at  tliat  time  about  seven  or  eight  days  ill.  She  had  on  ad- 
mission the  usual  symptoms  of  fever,  accompanied  by  intense  bron- 
chitis, dyspnoea,  costiveness,  and  loss  of  sleep.  Under  the  use  of  cup- 
ping, bhsters,  calomel,  and  other  appropriate  means,  the  fever  and  pul- 
monary symptoms  decHned,  and  she  was  pronounced  convalescent  on 
the  12th.  On  the  18th  she  had  been  up  as  usual,  but  towards  evening 
complained  of  rigors,  and  said  she  felt  her  right  leg  very  painful.  The 
pain  of  the  limb  continued  next  day,  intermitted  during  the  follow- 
ing night,  but  returned  on  the  morning  of  the  20th  with  increased 
violence.  She  was  leeched  without  much  relief,  and  on  the  21st  she  is 
reported  to  be  extremely  feverish,  her  pulse  frequent,  her  tongue  foul, 
bowels  loose.  She  had  passed  a  bad  night,  and  the  leg  was  still  ex- 
quisitely painful  and  somewhat  swollen.  She  had  twelve  leeches  again 
applied  with  some  relief,  but  on  the  22d  the  left  shoulder  became  simi- 
larly affected  with  pain,  and  so  tender  as  not  to  admit  of  the  slightest 
pressure.  On  the  23d  there  was  some  diminution  of  pain  in  the  leg 
and  shoulder,  but  her  pulse  was  jerking  and  unequal;  her  tongue 
parched ;  her  countenance  anxious ;  and  she  complained  of  intense  pain 
in  tlie  small  of  the  back.  She  passed  a  sleepless  night,  and  next  day 
complained  of  exquisite  pain  in  the  left  lower  extremity.  This  was  ac- 
companied by  an  exacerbation  of  the  febrile  symptoms;  she  moaned 
constantly ;  her  pulse  became  excessively  feeble  and  rapid ;  and  she 
died  on  the  24th. 

On  dissection,  the  peritoneum,  particularly  that  portion  of  it  attached 
to  the  abdominal  parietes,  was  found  remarkably  vascular,  the  vascu- 
larity being  most  intense  over  the  hypogastric  region.  There  was  no 
effusion  of  lymph  or  serum,  but  about  half  an  ounce  of  purulent  fluid 
was  discovered  in  the  cavity  of  the  pelvis.  The  viscera  were  healthy. 
The  internal  surface  of  the  principal  venous  trunks  was  tinged  red,  and 
there  was  a  small  quantity  of  coagulated  blood  in  their  cavities.  On 
making  an  incision  into  the  right  leg,  along  the  course  of  the  internal 
saphena,  the  subcutaneous  areolar  membrane  was  found  infiltrated  with 
sero-sanguineous  fluid;  the  texture  of  the  veins  was  here  apparently 
natural,  their  cavity  pervious  and  fiUed  with  fluid  blood,  without  any 
lymphy  or  purulent  admixture.  No  distention  or  enlargement  of  the 
lymphatics  was  observed. 

Here  you  have  a  case  corresponding  in  its  main  points  with  the  former, 
and  differing  from  it  chiefly  in  being  complicated  with  peritoneal  inflam- 
mation and  synovitis  of  the  shoulder-joint.  Its  origin  was  similar ;  it 
exhibited  the  same  kind  of  intense  neuralgic  pain ;  the  same  fever ;  the 
same  extensive  diffusion  of  local  inflammation,  and  the  same  unfavour- 
able termination.     The  chief  points  of  difi'erence  were,  that  in  the  latter 


S66  CLINICAL   MEDICINE. 

case  the  disease  attacked  the  synovial  membrane  of  the  shoulder-joint, 
and  the  serous  membrane  of  the  abdominal  cavity.  This,  however,  is  by 
no  means  unusual.  As  to  the  synovitis,  I  have  observed  it  in  more  than 
one  instance  after  fever.  •  I  have  ^vitnessed  a  very  remarkable  instance 
of  it  in  a  man  in  this  hospital  who  was  attacked  with  swelled  leg  after 
fever.  In  addition  to  the  affection  of  the  leg,  he  had  also  synovitis  of 
the  knee-joint  of  so  severe  and  intractable  a  character  that  he  recovered 
with  difficulty,  with  an  anchylosed  state  of  the  joints.  On  the  whole, 
the  disease  which  we  have  been  considering  is  one  of  great  importance, 
and  deserves  particular  attention.  It  is  sometimes  of  a  very  unmanage- 
able character,  and  baffles  our  best  directed  efforts.  The  treatment  which 
appears  best  adapted  for  it  consists  in  leeching,  fomentations,  and  the 
application  of  mercurial  ointment  with  extract  of  belladonna  to  the 
affected  parts :  these,  combined  with  the  internal  use  of  quina  and 
opium,  with  occasional  doses  of  calomel,  seem  to  comprise  the  chief  re- 
medies on  which  we  can  place  any  reliance. 

Before  I  conclude  this  lecture  I  shall  allude  briefly  to  the  very  inter- 
esting case  of  Sarah  O'Neil.  This  young  woman  was  admitted  on  the 
17th  of  February,  having  been  attacked,  on  the  lOth,  with  fever  of  the 
ordinary  type.  On  the  day  after  her  admission,  she  complained  of  want 
of  sleep,  and  pain  of  the  forehead  and  temples ;  but  she  had  no  raving, 
tinnitus  aurium,  intolerance  of  light,  or  other  symptom  of  inflamma- 
tion of  the  brain.  She  had  been  confined  about  a  fortnight  before  she 
came  in,  and  complained  that  her  breasts  were  very  troublesome  to  her. 
Her  belly  was  soft  and  faUen,  quite  free  from  tenderness  or  soreness, 
and  she  stated  that  her  bowels  were  free.  Her  tongue  was  furred,  her 
pulse  130,  the  locliia  suppressed  for  the  last  two  days.  Things  went 
on  tolerably  well  for  four  or  five  days,  when  her  beUy  became  tympani- 
tic, and  she  began  to  complain  of  pain  on  pressure.  The  action  of  the 
heart  now  became  more  violent ;  her  pulse  rose  to  140,  and  blood  began 
to  appear  in  her  stools.  On  the  24th  of  Eebruary — ^that  is  to  say, 
about  the  fourteenth  day  of  her  illness — her  pulse  was  150 ;  she  passed 
a  large  quantity  of  blood  from  the  bowels,  and  the  tympanitis  subsided. 

In  cases  of  fever  accompanied  by  tympanitis  and  signs  of  intestinal 
congestion,  hemorrhage  from  the  bowels,  particularly  when  it  occurs  on 
one  of  the  critical  days,  should  not  be  interfered  with.  It  is  in  this 
way  that  nature  very  frequently  brings  about  relief  of  the  congestion 
and  irritation  of  the  gastro-intestinal  raucous  membrane,  just  as  she 
relieves  congestion  of  the  head  by  bleeding  from  the  nose.  In  the  case 
of  a  lady  whom  I  attended  along  with  Mr.  Palmer,  some  time  ago,  at 
Drumcondra,  the  occurrence  of  intestinal  hemorrhage  was  followed  by 
the  most  marked  effects ;  her  beUy  became  soft,  the  tympanitis  disap- 


HEMORRHAGE    FROM   THE    BOWELS    IN    FEVER.  267 

pearecl,  and  all  her  febrile  symptoms  were  speedily  removed.  The  ap- 
pearance of  blood,  therefore,  at  such  periods  and  under  such  circum- 
stances, is  to  be  looked  on  as  a  favourable  occurrence ;  nor  should  it 
be  interfered  with  in  any  way  until,  from  its  continuance  or  its  quantity, 
it  appears  likely  to  produce  debilitating  effects. 

In  the  present  case,  however,  this  hemorrhage  will  require  to  be  very 
carefully  watched.  The  woman's  system  is  that  which  is  favourable  to 
profuse  fluxes  of  blood,  for  it  is  not  long  since  her  accouchement,  and 
she  has  suppression  of  the  lochia.  She  has  had  but  little  fever  for  the 
last  two  or  three  days,  but  the  action  of  the  heart  still  continues  ex- 
tremely violent,  and  her  pulse  is  still  rising.  Eespiration,  too,  has  been 
considerably  accelerated;  and,  where  this  occurs,  you  have  always 
reason  to  apprehend  danger.  I  have  accordingly  endeavoured  to  mo- 
derate the  hemorrhage  by  the  use  of  acetate  of  lead  and  opium.  A 
draught  composed  of  acetate  of  lead,  eight  minims  of  tincture  of 
opium,  and  fifteen  minims  of  wine  vinegar,  in  six  drachms  of  water, 
has  been  prescribed  to  be  taken  as  occasion  requires.  A  large  bhster 
has  been  applied,  so  as  to  cover  the  epigastrium  and  sternum,  and  she 
has  been  allowed  port  wine  and  chicken  broth.  Where  a  patient,  de- 
bihtated  by  previous  fever,  has  been  attacked  with  hemorrhage,  you 
should  be  careful  in  supporting  the  system  by  small  quantities  of  wine, 
and  light  nutritious  food ;  for  there  is  always  more  or  less  danger  to  be 
apprehended  of  a  sinking  of  the  powers  of  life.  In  cases  of  this  kind 
the  cautious  use  of  acetate  of  lead,  with  opium  and  wine,  are  the  only 
means  on  which  we  can  rely  with  any  confidence. 


268 


LECTURE  XX. 

NEEVOUS     FEVER. CAUTION     AS     TO     PROGNOSIS. PRESCRIPTIONS     IN 

EEVER. CONCLUDING   REMARKS. 

Permit  me  to  make  one  or  two  observations  on  a  case  of  wliich  I  have 
already  spoken,  and  which,  as  I  expected,  has  terminated  fatally.  A 
man,  named  Lynam,  has  been  lying  ill  for  a  long  time  in  a  large  fever 
ward ;  I  wrote  at  the  top  of  his  card  "  Nervous  Pever,'^  and  remarked 
to  the  class  that  his  disease  was  pure  fever,  of  a  nervous  type,  unac- 
companied by  any  symptoms  indicating  decided  local  inflammation. 
You  will  recollect  that  his  symptoms  were  heat  of  skin,  quick,  weak, 
compressible  pulse,  thirst,  watchfulness,  and  low  muttering  delirium,  un- 
attended with  any  appreciable  sign  of  visceral  disease,  or  any  symptoms 
denoting  a  putrescent  state  of  the  fluids.  It  was  not  congestive  or  pu- 
trid, or  gastro-enteric,  or  petechial  fever;  neither  could  it  be  called  a 
cerebral  fever ;  it  was  only  by  separating  from  it  the  idea  of  each  of 
these  species,  and  by  studying  its  negative  characters,  that  you  could 
arrive  at  something  like  an  accurate  conception  of  the  type  of  the  dis- 
ease. It  was,  as  I  have  already  stated,  nervous  fever,  modified  by  the 
patient^s  previous  habits  of  long-continued  intemperance.  When  a 
patient,  addicted  to  intemperate  habits,  gets  an  attack  of  fever  from 
cold,  fatigue,  or  exposure  to  contagion,  you  will  generally  find  the  dis- 
ease exliibit  a  compound  or  mixed  character,  the  phenomena  of  fever 
being  combined  with  those  of  delirium  tremens.  And  so  it  was  in  this 
case ;  the  man  had  general  tremors,  mth  persistent  watchfulness,  and 
muttering  delirium. 

His  treatment  consisted  in  the  employment  of  medicines  calculated 
to  soothe  the  nervous  system,  and  I  kept  a  constant  watch  over  the 
state  of  the  principal  viscera.  About  a  week  after  he  came  under  my 
care,  and  about  five  weeks  from  the  commencement  of  his  fever  (for  he 
was  nearly  a  month  ill  before  he  came  to  the  hospital),  he  was  attacked 
with  erysipelatous  inflammation  of  the  face  and  scalp.  The  disease 
commenced  on  the  face,  and,  travelling  upwards,  very  rapidly  attacked 


NERVOUS    FEVER.  2(39 

the  whole  scalp  and  back  of  the  neck,  its  progress  being  accompanied 
by  great  aggravation  of  symptoms.  At  that  time  I  remarked  to  the 
class  that  I  did  not  entertain  any  apprehension  of  a  metastasis  of  the 
erysipelas,  that  I  had  no  fears  of  the  supervention  of  inflammation  of 
the  brain,  and  its  train  of  alarming  consequences ;  but  that  no  good 
was  portended  by  this  attack  of  cutaneous  inflammation,  and  no  relief 
of  the  internal  parts  could  be  expected  from  it,  for  every  symptom  ap- 
peared aggravated  from  the  moment  that  the  erysipelas  commenced. 
I  pointed  out  the  total  inadmissibility  of  any  thing  like  vigorous  or 
antiphlogistic  treatment,  in  a  case  w'here  the  disease  had  appeared  in  an 
individual  of  broken  constitution,  labouring  under  a  combination  of 
delirium  tremens  with  low  fever ;  and  said  that  even  the  remedy  which 
we  had  found  most  successful  in  similar  cases,  namely,  sulphate  of  quina 
and  opium,  offered  but  a  feeble  hope  of  arresting  the  malady.  It 
failed,  as  we  expected,  and  the  man  died  yesterday,  worn  out  by  long 
suffering  and  exhaustion.  Eighteen  hours  after  death  we  made  a  most 
careful  examination  of  all  the  viscera  of  the  three  great  cavities ;  not  a 
single  organ  exhibited  the  least  mark  of  inflammation ;  we  could  not 
find  any  w^here  even  the  slightest  trace  of  local  congestion.  The  man 
had  all  his  viscera  in  an  apparently  sound  and  normal  condition,  and 
died  of  pure  nervous  fever. 

Some  persons  look  upon  the  existence  of  fever  independent  of  topi- 
cal affections  as  purely  imaginary,  and  deem  those,  who  have  recorded 
such  forms  of  disease,  as  too  ignorant,  or  too  lazy,  to  make  the  neces- 
sary pathological  investigations.  I  have  not  time  at  present  to  enter 
into  this  subject,  but  of  nothing  am  I  more  convinced,  than  that  fever 
may  exist  wdthout  any  appreciable  local  lesion,  that  it  may  affect  every 
organ  and  every  tissue  of  the  body  alike,  and  yet  that  the  most  accur- 
ate symptomatologist  cannot  put  his  finger  on  any  one  single  part  and 
say,  here  is  local  inflammation  of  a  decided  character.  I  have  met 
with  many  instances  confirmatory  of  this  fact  in  hospital  practice.  I 
recollect  a  case  which  occurred  some  time  ago  at  this  hospital,  whicli 
was  equally  as  remarkable  for  its  extraordinary  duration,  as  for  the  total 
absence  of  any  thing  like  visceral  lesion.  The  patient  was  admitted 
into  the  small  fever  ward,  labouring  under  an  attack  of  nervous  fever ; 
he  had  thirst,  hot  skin,  pulse  from  110  to  ]  20,  occasional  delirium  and 
watchfulness,  and  these  symptoms  went  on  week  after  week,  and  month 
after  month,  unaccompanied,  during  the  whole  course  of  the  disease, 
by  any  phenomena  indicating  the  existence  of  local  inflammation.  His 
treatment  was  purely  expectant  and  temporising ;  w^e  had  no  cerebral, 
abdominal,  or  thoracic  lesion  to  combat ;  there  was  no  organ  in  which 
the  febrile  derangement  could  be  said  to  have  fixed  itself  exclusively, 


270  CLINICAL   MEDICINE. 

no  threatening  disorganization  calling  for  tlie  employment  of  prompt, 
new,  and  energetic  means.  At  last,  after  the  fever  had  continued  for 
very  nearly  three  months,  the  man  complaining  all  the  time  of  more  or 
less  thirst,  hot  skin,  watchfulness,  and  headache,  with  occasional  deli- 
rium, the  disease  terminated  in  a  well-marked  crisis,  accompanied  by 
sweating.  He  fell  asleep,  began  to  perspire,  awoke  with  a  pulse  nearly 
reduced  to  the  natural  standard,  and  perfectly  recovered.  I  may  ob- 
serve that  I  have  never  seen  fever  last  so  long  as  this,  nor  have  I  ever 
observed  a  perfect  crisis  in  any  case  after  the  forty-second  day.  Some 
time  ago  I  attended  the  brother  of  a  gentleman  now  present,  who  had 
a  long  and  very  severe  attack  of  fever ;  though  he  never  had  a  remis- 
sion during  his  illness,  and  was  in  very  urgent  danger,  he  got  a  perfect 
crisis  with  profuse  perspiration  on  the  forty-second  day,  and  is  now  in 
the  enjoyment  of  excellent  health. 

You  perceive,  then,  that  the  case  of  Lynam  presents  some  circum- 
stances worthy  of  notice.  His  fever  went  on  to  its  termination  without 
any  symptoms  of  inflammation  in  any  viscus,  and  his  actual  condition, 
as  carefully  ascertained  by  an  accurate  post-mortem  examination,  affords 
a  useful  lesson  to  the  pathologist.  His  case  is  also  interesting  as  show- 
ing how  previous  habits  will  modify  in  a  remarkable  degree  the  cha- 
racter of  fever ;  for  in  him  you  have  seen  fever  combined  with  the 
phenomena  of  delirium  tremens,  a  state  of  things  which  it  was  natural 
to  expect  in  a  man  of  extremely  intemperate  habits.  The  termination 
of  the  erysipelas  without  any  sign  of  disorganization  within  the  cranium 
is  also  worthy  of  notice.  In  such  cases  you  have  it  frequently  followed 
by  inflammation  of  the  brain  and  its  membranes,  and  an  exudation  of 
pus  on  the  surface  of  one  or  both  the  hemispheres ;  but  here  you  per- 
ceive that  there  has  been  no  extension  of  the  disease,  nor  anything  that 
should  have  induced  us  to  give  up  the  plan  of  treatment  we  adopted, 
and  direct  our  therapeutic  means  to  the  head. 

There  is  another  man,  named  Vero,  in  the  fever  ward,  whose  case  I 
beg  you  wdll  study  with  attention.  He  applied  for  admission  here  some 
time  ago,  labouring  under  violent  and  general  bronchitis,  accompanied 
by  high  inflammatory  fever ;  we  took  him  in  at  the  time,  as  his  case 
was  one  of  the  most  urgent  danger,  but  were  obhged,  by  the  crowded 
state  of  the  hospital,  to  put  him  into  the  large  fever  ward.  It  is  un- 
necessary for  me  to  detail  the  treatment  employed,  as  you  have  all 
witnessed  it.  By  the  most  energetic  measures,  we  succeeded  in  arresting 
the  disease,  but  his  convalescence  was  rendered  tedious  in  consequence 
of  his  having  been  suddenly  affected  by  a  small  quantity  of  mercury. 
His  mouth  became  very  sore,  his  breath  fetid,  his  gums  spongy,  the 
inside  of  his  hps  covered  with  lymph,  and  his  system  exliibited  all  the 


NERVOUS    FEVER,  271 

marks  of  mercurial  irritation;  but^  under  the  care  of  Mr.  Grady,  a 
gradual  but  decided  improvement  in  his  condition  was  going  on,  and 
he  was  advancing  rapidly  in  convalescence,  when,  unluckily  for  himself, 
he  was  persuaded  to  leave  the  hospital  for  the  sake  of  voting  at  the 
city  of  Dublin  election.  In  doing  tliis,  he  was  necessarily  much 
fatigued,  and  was  exposed  to  cold  on  returning  from  the  heated  booth. 

Now,  mark  the  consequences  of  this  indiscretion.  This  man  just 
arrived  at  the  period  of  convalescence  from  a  severe  and  dangerous  in- 
flammatory fever,  and  greatly  debilitated  both  by  the  disease  and  the 
venesections  and  other  remedies  necessarily  employed,  improvidently 
exposes  himself  while  his  frame  was  still  emaciated  and  weak,  and  while 
his  mouth  was  still  sore  in  consequence  of  severe  mercurial  salivation : 
in  this  condition  he  exposes  himself  to  the  operation  of  mental  excite- 
ment, great  bodily  fatigue,  and  cold — and  what  have  been  the  conse- 
sequences  ? — Why,  that  a  new  attack  of  fever  immediately  struck  him 
to  the  ground  with  a  heavy  hand,  and,  after  an  absence  of  ten  days, 
he  returned  to  the  hospital  on  the  24th  of  January,  complaining  of 
rigors,  and  other  symptoms  indicative  of  commencing  fever.  We  saw 
him  next  morning,  that  is,  before  this  new  fever  had  lasted  more  than 
twenty-four  hours,  and  we  found  him  affected  in  a  most  remarkable 
manner ;  we  found  him  labouring  under  a  number  of  severe  symptoms, 
which  would  have  led  the  most  experienced,  if  asked  to  guess  how 
long  his  fever  had  already  lasted,  into  the  commission  of  a  gross  error, 
for  he  would  answer  that  it  must  be  at  least  the  eleventh  day.  It  is, 
indeed  very  rare  to  find  fever,  at  once  commencing  with  symptoms  such 
as  we  observed  on  the  first  day  in  Vero.  Great  prostration  of  strength, 
hot  skin,  dry  tongue,  pulse  108,  nervous  agitation,  restlessness,  toge- 
ther with  subsuUus  tendinum,  were  present  from  the  commencement. 
The  subsultus  was  very  remarkable,  and  increased  to  such  a  degree, 
even  on  the  second  day,  that  Mr.  Grady  found  it  very  difficult  to  count 
the  pulse  at  the  wrist ;  and  yet,  though  his  muscular  system  was  thus 
irregularly  excited,  and  its  nervous  influence  deranged,  he  had  not  even 
a  tendency  to  delirium,  and  he  slept  soundly ;  neither  had  he  the  least 
headache. 

I  called  your  attention  to  this  circumstance  at  the  bed  of  the  patient, 
and  I  endeavoured  to  impress  strongly  on  your  minds  how  forcibly  this 
case  opposes  the  doctrines  of  those  who  attribute  all  the  nervous  dis- 
turbance of  every  part  of  the  system,  and,  amongst  the  rest,  subsultus, 
to  congestion  or  to  inflammation  of  the  brain.  When  the  subsultus 
had  attained  to  a  degree  of  violence  in  Yero's  case,  such  as  we  seldom 
witness,  we  remarked,  nevertheless,  that  he  slept  well,  had  a  clear  eye, 
without  the  least  approach  to  suffusion,  and  that  he  was  free  from 


272  CLINICAL  MEDICINE. 

lieadaclie,  heat  of  scalp,  or  throbbing  of  the  temporal  arteries.  Nei- 
ther were  we  able  to  detect  the  slightest  indication  of  inflammation,  or 
even  of  congestion,  in  the  chest  or  abdomen.  The  breathing  was 
indeed  quickened,  but  only  in  proportion  to  the  acceleration  of  the 
pulse,  and  there  was  no  cough  or  thoracic  pain  or  uneasiness.  The 
belly  was  fallen,  soft,  and  quite  free  from  tenderness ;  and  there  were 
no  griping  pains,  flatulence,  nausea,  or  diarrhoea,  and  yet  the  patient 
was  evidently  very  dangerously  ill.  Agitated  with  subsultus,  he  was 
in  a  constant  state  of  restlessness  when  awake ;  his  skin  was  hot,  his 
tongue  dry,  and  his  weakness  was  sudden  and  excessive ;  in  short,  he 
was  labouring  under  intense  nervous  fever.  This  is  a  rare  form  of  dis- 
ease, and  one  the  very  existence  of  which  most  modern  pathologists 
have  been  in  the  habit  of  denying ;  but,  as  I  told  you  before,  I  have 
seen  several  examples  of  it. 

I  may  remark  that,  in  the  present  epidemic  fever,"^  the  termination 
of  the  disease  by  a  well-marked  crisis  never  occurs.  Now,  in  the 
epidemic  fever  of  which  I  have  spoken  in  a  former  lecture,  and  wliich 
committed  such  devastations  in  1826,  a  crisis  was  observable  in  the 
majority  of  the  cases,  and  was  almost  always  preceded  by  rigors  and  a 
hot  fit,  attended  for  a  few  hours  with  marked  exacerbation  of  the  symp- 
toms, and  followed  by  a  most  profuse,  warm,  general  perspiration, 
bringing  perfect  relief,  and  often  so  excessive  tliat  the  steam  of  it  could 
be  seen  issuing  forth  in  vapour  through  the  blankets  in  which  the  pa- 
tient lay  wrapped.  In  the  beginning  of  the  epidemic,  the  critical  rigor 
often  took  place  on  the  fifth  day,  and  oftener  on  the  seventh,  but,  as 
the  disease  continued,  these  short  fevers,  which,  by  the  by,  always 
left  the  patient  very  liable  to  relapse,  entirely  disappeared ;  and  when 
the  epidemic  reached  its  acme,  the  crisis  rarely  took  place  so  early  as  on 
the  eleventh  day,  and  most  general  on  the  fourteenth  or  seventeenth  day. 

You  perceive,  that  in  judging  of  the  truth  of  the  doctrines  held  by 
the  ancients,  concerning  the  existence  of  critical  days  in  fevers,  an 
observer  of  the  present  epidemic  might  be  led  into  error,  and  might, 
by  generahsing  too  hastily,  arrive  at  the  false  conclusion  that  this  doc- 
trine of  critical  days  is  totally  destitute  of  foundation.  But  to  return 
to  our  patient  Yero.  It  is  not  very  difficult  to  explain  why,  in  liim, 
the  moment  fever  was  excited  it  assumed  the  nervous  type.  He  had 
been  debilitated  by  severe  inflammatory  fever  and  by  the  active  anti- 
phlogistic treatment,  and,  above  all,  his  nervous  system  had  been  se- 
verely tried  by  an  unexpected  mercurial  salivation,  brought  on  by  an 
unusually  small  quantity  of  calomel. 

*  1834-35. 


PROGNOSIS    IN    FEVER.  273 

You  are  aware  that  various  nervous  symptoms  attended  with  irregular 
muscular  action,  and  simulating  chorea,  or  paralysis  agitans,  are  fre- 
quently the  result  of  metallic  salts,  whether  lead  or  mercury.  For  this 
reason,  I  look  upon  the  previous  mercurialisation  as  the  chief  cause  of 
the  nervous  type  of  Yero's  fever.  In  spite  of  all  our  efforts,  he  died 
exhausted  on  the  tenth  day. 

As  long  as  life  lasts,  no  matter  how  fatal  the  symptoms  may  appear 
to  be,  you  should  never  despair  of  recovery  in  fever.  You  will  find 
many  examples  of  recovery  in  the  most  hopeless  cases  in  the  lectures 
which  I  have  given  you  on  this  disease,  but  I  cannot  forbear  quoting 
the  following  striking  illustration  which  occurred  in  the  practice  of  Dr. 
Hudson,  of  Navan.  He  consulted  me  as  to  the  treatment  during  con- 
valescence, and  I  shall  read  for  you  his  report : — 

"Miss  B appears  to  have  sickened  about  the  9th  or  10th  of 

June,  1844^,  but  I  did  not  see  her  until  the  20th.  She  had  then  some 
very  serious  symptoms.  She  complained  of  extreme  debility,  had 
much  subsultus,  constant  sweatings,  diarrhoea  and  meteorism,  and  un- 
usually severe  headache.  I  ordered  a  few  leeches  to  be  applied  behind 
the  ears,  and  for  some  days  endeavoured  to  keep  the  diarrhoea  in  check 
by  small  doses  of  hydrargyrum  cum  creta  and  Dover's  powder.  It 
increased,  however,  and  I  applied  a  blister  over  the  coecum  and  gave 
acetate  of  lead  until  a  check  was  given  it.  By  this  time  (five  or  six 
days  after  my  first  visit)  the  head  had  become  more  seriously  engaged. 
She  had  low  muttering,  lay  on  her  back,  had  involuntary  evacuations, 
&c.,  and  diarrhoea  set  in  more  smartly  than  ever.  I  applied  a  blister 
to  the  nape  of  the  neck,  gave  port  wine  in  small  quantities  pretty  fre- 
quently, and  decoction  of  bark,  with  aromatic  confection,  and  occasional 
doses  of  musk  and  camphor.  I  ceased  giving  acetate  of  lead  by  the 
mouth,  and  ordered  an  enema  of  four  grains  of  the  acetate  and  four 
drops  of  laudanum  to  be  given  on  each  return  of  the  diarrhoea.  This 
treatment  gave  it  a  final  check,  and  though  the  poor  patient's  weakness 
was  now  extreme,  still  I  had  hopes  that  she  would  fight  it  out ;  but  on 
the  night  of  June  30th,  a  fearful  change  came  on.  Cold  skin,  suc- 
ceeded by  heat  and  excessive  greasy  perspirations,  laborious  breathing 
with  loud  rales,  fluttering  pulse,  at  times  imperceptible,  &c.  &c.  I 
■was  sent  for  early  on  the  following  morning,  and  found  her  breathing 
loudly  and  hurriedly,  with  stertor ;  the  eye  fixed  and  glassy,  pupils 
contracted  to  a  point,  face  bloated  and  livid,  loud  rales  throughout  the 
chest.  I  found  it  not  possible  to  arouse  her  to  consciousness.  The 
abdomen  was  swelled  and  tympanitic  to  an  enormous  extent. '  She  had 
convulsive  twitchings  of  the  mouth,  a  commencing  puff  in  the  respira- 
VOL.  I.  18 


274  CLINICAL   MEDICINE. 

tioii.  In  factj  she  seemed  dying ;  and  as  the  closing  act  of  the  fever 
seemed  to  be  a  sudden  pulmonary  congestion^  I  proposed  to  try  the 
desperate  chance  of  a  bleeding,  if  only  to  gain  a  little  time  for  further 
measures.  I  accordingly  took  away  four  ounces  from  the  arm,  and 
immediately  applied  sinapisms  to  the  spine  and  feet,  and  relays  of  hot 
flannel,  sprinkled  with  turpentine,  to  the  belly,  giving  a  few  drops  of 
the  oil  of  turpentine  in  brandy  punch.  The  turgescence  and  livid 
colour  left  the  face  after  the  bleeding,  and  never  returned ;  but  in  any 
other  respect,  save  that  the  breathing  was  a  little  easier,  I  did  not  see 
any  improvement  during  three  hours  that  I  stayed,  and  I  left  without 
a  hope  of  her  surviving  many  hours.  Hearing,  vision ,  and  conscious- 
ness were  lost,  and  nothing  hut  the  power  of  swallowing  remained. 
While  this  continued,  I  directed  brandy  and  water  to  be  given  every 
half  hour. 

"During  tlie  following  night  she  seemed  to  be  getting  gradually 
weaker,  and  the  pulse  toward  morning  became  irregular  and  fluttering ; 
but  as  she  continued  to  live  on,  and  even  began  to  show  that  she  saw 
and  knew  those  about  her,  her  mother  again  sent  to  me,  stating  how 
she  was,  and  leaving  me  to  decide  whether  anything  more  should  be 
done.  As  the  respiration  still  continued  to  be  laborious  and  accom- 
panied by  rales,  I  recommended  flying  blisters  over  the  course  of  the 
eighth  pair  which  you  used  formerly  to  advise  in  certain  cases — a  prac- 
tice which  I  have  often  seen  followed  by  the  best  effects,  and  apparently 
so  here ;  for,  as  I  remained  with  the  patient  during  the  night,  I  marked 
a  gradual  improvement  as  the  blisters  produced  their  effect,  and  though 
I  was  still  most  anxious  about  her,  she  was  nevertheless  incomparably 
better,  for  the  pulse  became  steady  and  full,  and  averaged  very  little 
over  100.  The  breathing  was  less  hurried  and  laborious,  though  still 
far  from  easy ;  the  meteorism  had  entirely  subsided,  and  in  the  morning 
she  passed  some  solid  fseces.  The  urine  passed  during  the  day  of  the 
1st  of  August  was  the  most  remarkable  I  ever  saw.  It  exactly  resem- 
bled porter  with  a  thick  layer  of  chalk  deposited.  The  horrible  sweat 
ceased,  and  the  skin  became  moderately  warm  and  soft.  I  now  with- 
drew my  stimulants,  except  a  little  brandy  punch  at  longer  intervals, 
and  gave  small  doses  of  senega  and  carbonate  of  ammonia.^^ 

From  the  date  of  Dr.  Hudson's  report,  which  closes  here,  this  young 
lady  gradually  but  slowly  recovered.  No  case  could  teach  you  more 
decidedly  the  necessity  for  a  cautious  prognosis  in  fever,  and  that  you 
should  never  relax  your  treatment  in  despair  of  recovery. 

Before  concluding  the  subject  of  fever,  I  wish  to  speak  of  some  pre- 
scriptions which  I  am  in  the  habit  of  using.      In  the  treatment  of 


PRESCRIPTIONS    IN    FEVER.  275 

fever  it  is  frequently  of  importance  to  gain  time,  and  periods  will  occur 
in  every  long  fever,  in  wliicli  there  may  be  no  direct  indication  for  the 
exhibition  of  any  powerful  remedy ;  at  the  same  time,  such  is  the  ig- 
norance of  non-medical  persons,  and  the  anxiety  of  the  patient/s  friends 
is  so  intense,  that  they  cannot  imagine  how  it  is  possible  for  an  atten- 
tive physician  to  let  twelve  hours  pass  away  without  doing  something. 
The  mere  circumstance  of  seeing  the  fever  going  on,  is  sufiicient  proof 
to  them  of  the  necessity  of  making  renewed  efforts  for  its  removal. 
This,  however,  is  very  excusable.  If  any  of  you  happened  to  be  ill, 
I  dare  say  you  could  scarcely  bear  to  pass  many  hours  without  taking 
something  which  you  supposed  might  prove  either  immediately  or 
remotely  useful.  Consequently,  we  could  not  treat  fever  in  a  satisfactory 
manner  without  medicines  of  what  may  be  termed  an  expectant  cha- 
racter, and  calculated  to  fill  up  the  spaces  intervening  between  those 
periods  when  active  treatment  is  necessary.  You  are  not  to  suppose 
that  in  ordering  such  medicines  you  are  acting  a  dishonest  part,  and 
practising  a  deception  unworthy  of  your  profession ;  on  the  contrary, 
your  conduct  is  perfectly  just  and  proper ;  and  though  you  are  con- 
vinced that  no  medicine  is  required,  still  it  will  be  necessary  to  pre- 
scribe something,  if  you  do  not  wish  to  lose  the  confidence  of  the 
patient  and  his  friends. 

Again,  if  at  a  period  when  you  say  that  no  medicine  is  necessary, 
and  w^hen  the  patient  has  passed  twenty-four  hours  or  two  days  without 
taking  anything,  an  unexpected  turn  in  his  disorder  should  take  place, 
people  will  be  very  apt  to  say,  either  that  you  did  not  know  what  to 
do,  or  that  you  took  no  steps  to  obviate  the  threatened  change,  and 
that  one  or  two  days  were  completely  lost.  Conduct  like  this  has  fre- 
quently brought  down  a  great  deal  of  censure  on  medical  men.  It 
may  be  said  that  these  are  mere  prejudices,  and  above  the  dignity  of  a 
man  of  firm  and  consistent  character;  but  since  prejudices  are  inti- 
mately blended  with  human  nature,  and  constitute,  as  it  were,  a  part 
of  it,  it  is  much  better  in  many  cases  to  submit  to  them,  particularly 
when  compliance  does  not  involve  a  sacrifice  of  principle.  In  cases  of 
acute  disease  of  any  considerable  duration,  and  especially  in  private 
practice,  there  are  periods  when  medicines  of  an  expectant  and  tem- 
porising character  must  be  employed ;  and  hence  the  introduction  of  a 
class  of  remedies  extensively  used  in  fever  and.  other  complaints,  and 
generally  denominated  palHatives.  These  are  remedies  which  have  a 
general  tendency  to  assuage  thirst,  act  as  diluents,  gently  promote  the 
secretions  of  the  skin,  intestinal  canal,  or  kidneys,  and  which  are 
known  to  possess  at  least  the  negative  quality  of  doing  no  harm.  They 
are   most   commonly  prescribed   in   combination  with  a  considerable 


276  CLINICAL   MEDICINE. 

quantity  of  fluid,  and  hence  are  administered  either  in  the  form  of 
drauglit  or  mixture.  The  medicine  in  most  general  use  among  the 
physicians  of  Dublin  is  one  which  was  introduced  by  Dr.  Cheyne.  It 
is  prepared  by  dissolving  a  drachm  of  carbonate  of  ammonia  in  three 
ounces  and  a  half  of  water,  with  as  much  lemon  juice  as  will  saturate 
it;  the  mixture  is  then  sweetened  with  syrup  of  orange  peel,  and 
given  in  doses  of  two  tablespoonfuls  every  third  or  fourth  hour. 
In  this  way  a  solution  of  the  citrate  of  ammonia  is  formed,  which 
possesses  the  properties  of  a  mild  anti-febrile,  and  gently  stimulant 
diaphoretic. 

Kow  it  cannot  be  denied  that  this  mixture  answers  the  purposes  of 
an  expectant  remedy,  calculated  to  pass  away  the  time,  and  do  no  injury ; 
but  it  appears  to  labour  under  one  considerable  disadvantage,  it  is  not 
agreeable  to  the  taste.  If  you  taste  the  citrate  or  acetate  of  ammonia, 
you  will  find  that  its  flavour  is  by  no  means  pleasant,  and  I  need  not 
tell  you  that  in  cases  where  there  is  no  actual  indication  to  be  fulfilled, 
it  is  of  importance  to  have  something  that  will  not  be  disagreeable  to 
the  patient.  Teeling,  therefore,  the  necessity  of  altering  this  prescrip- 
tion, I  have  lately  introduced  another,  which  I  am  happy  to  find  has 
been  extensively  adopted,  and  which  is  formed  by  substituting  the  car-, 
bonate  of  soda  for  the  carbonate  of  ammonia.  The  mode  in  which  I 
generally  employ  it  is  the  following : — carbonate  of  soda,  a  drachm ; 
water,  four  ounces;  lemon  juice,  a  sufficient  quantity  to  saturate  the 
alkali ;  syrup  of  orange  peel,  half  an  ounce ;  tincture  of  orange  peel, 
two  drachms.  A  little  more  than  an  ounce  and  a  half  of  lemon  juice 
will  be  sufficient  to  saturate  this  quantity  of  carbonate  of  soda,  whereas 
it  would  take  from  two  and  a  half  to  three  ounces  to  saturate  the  same 
quantity  of  carbonate  of  ammonia.  If  you  \yish  to  have  a  weaker  so- 
lution, and  I  believe  it  is  the  better  way,  you  can  dissolve  a  drachm  of 
carbonate  of  soda  in  five  ounces  of  water  instead  of  four.  Nothing  can 
be  more  agreeable  in  flavour  than  this  mixture.  The  citrate  of  soda, 
which  is  formed,  does  not,  it  is  true,  exert  any  active  influence  on  the 
animal  economy,  but  it  partakes  in  the  properties  of  neutral  salts,  de- 
termines gently  to  the  kidneys,  tends  to  keep  up  a  soluble  state  of  the 
bowels,  and  forms  a  most  grateful  and  refreshing  beverage.  The  syrup 
of  orange  peel  gives  the  mixture  an  extremely  pleasant  flavour,  and 
this  is  further  heightened  by  the  agreeable  aromatic  bitter  of  the  tinc- 
ture. Since  I  commenced  using  it,  I  have  found  it  to  answer  all  the 
necessary  purposes  extremely  well,  and  I  can  recommend  it  to  you 
with  great  confidence. 

A  woman,  named  Anne  Scarlet,  was  admitted  on  Saturday,  concern- 
ing wliose  case  it  may  be  necessary  to  make   a  few  observations.     She 


INl'LAMMATION    OF   THE    MAMMAE    IN    TEVEll.  277 

states  that  she  has  been  ill  for  the  last  eight  days,  and  that  her  illness 
originated  in  cold,  preceded  by  rigors,  and  followed  by  feverish  symp- 
toms. The  general  pyrexia  had  subsided  at  the  period  of  her  admis- 
sion ;  but  she  had  some  symptoms  worthy  of  attention.  Her  pulse  was 
72,  and  regular ;  her  skin  rather  cool,  and  her  bowels  natural ;  but  she 
complained  of  acute  pain  in  the  left  side,  which,  she  said,  came  now  and 
then,  catching  her  breath,  and  preventing  her  from  taking  a  full  inspi- 
ration. This  pain  was  so  intense,  and  seemed  to  affect  respiration  so 
considerably,  that,  looking  to  its  situation  and  its  effects,  you  would  at 
first  sight  be  inclined  to  think  that  it  arose  either  from  pleurisy  or  peri- 
carditis. On  examining  the  chest,  however,  by  the  stethoscope  and 
percussion,  we  found  the  sound  was  clear  and  normal :  there  were  no 
rales  present,  and  the  respiratory  murmur  was  heard  distinctly  over  the 
whole  lung.  In  fact,  auscultation  showed  that  the  cause  of  the  pain 
was  not  connected  with  pleuritis,  pneumonia,  or  pericarditis.  What 
then  was  it  ?  A  variety  of  pleurodynia,  well  worthy  of  your  attention 
as  being  coimected  in  her  case  with  retention  of  the  milk  and  engorge- 
ment of  the  left  mamma.  At  the  time  she  was  attacked  with  cold,  she 
happened  to  be  only  a  few  days  after  childbirth ;  the  feverishness  which 
ensued  obliged  her  to  give  up  nursing,  and  in  this  way  a  sudden  and 
unnatural  check  was  put  upon  the  secretion  of  milk.  When  an  oc- 
currence of  this  kind  takes  place,  and  proper  means  are  not  taken  to 
obviate  the  mischief,  a  high  degree  of  local  irritation  is  the  consequence, 
producing  inflammation  of  one  or  both  the  mammae,  which,  if  not 
treated  well  and  energetically,  will  certainly  end  in  mammary  abscess. 

What  I  wish  to  draw  your  attention  to,  however,  at  present,  is  this — 
that  inflammation  of  the  mamma,  arising  from  retention  of  milk,  is 
very  apt  to  be  attended  with  pleurodynia  in  one  or  more  parts  of  the 
chest.  The  flow  of  milk  to  the  breasts,  three  or  four  days  after  deli- 
very, is  very  often  accompanied  by  flying  pleurodynia ;  and  the  formation 
of  mammary  inflammation,  from  the  arrest  of  lacteal  secretion,  is  also 
very  frequently  attended  with  fixed  pains  of  a  pleuritic  character. 

The  treatment  adopted  in  this  case  was  very  simple.  In  the  first 
place,  you  endeavour  to  check  the  determination  of  fluid  to  the  breast ; 
and  for  this  purpose  you  exhibit  a  purgative  of  an  hydragogue  kind, 
calculated  to  act  briskly  on  the  bowels.  We  gave  a  combination  of 
infusion  of  senna,  sulphate  of  magnesia,  tincture  of  senna,  and  electu- 
ary of  scammony,  which  acted  six  or  seven  times  on  the  bowels,  and 
tended  materially  to  relieve  by  derivation,  the  mammary  congestion. 
In  the  next  place,  we  directed  our  attention  to  the  breast,  and  endea- 
voured to  remove  the  milk,  by  the  use  of  the  syringe  employed  for 
that  purpose.     The  milk  may  be  removed  from  the  breast  by  means  of 


278  CLINICAL   MEDICINE. 

the  syringe^  or  by  sucking  with  a  breast  bottle^  and  where  the  tender- 
ness of  the  part  is  so  great  that  neither  of  these  modes  can  be  employed^ 
the  next  best  means  is  dihgent  fomentation.  Tliis  produces  a  con- 
stant oozing  from  the  breast,  and  if  the  fomentation  employed  be  made 
with  a  decoction  of  poppy  heads,  it  has  considerable  effect  in  abating 
pain  and  inflammation.  We  also  applied  leeches  in  this  case,  not  with 
the  view  of  removing  the  pleurodynia,  but  with  the  intention  of  removing 
its  cause,  mammary  inflammation.  By  the  use  of  means  directed  to 
the  breast,  you  will  find  that  we  can  remove  all  symptoms  of  pleuro- 
dynia, and  that  the  pain  and  difficulty  of  breathing  will  soon  disappear. 
This  is  a  simple  case,  but  it  is  one  of  frequent  occurrence,  and  it  re- 
quires some  tact  and  management  for  its  successful  treatment. 

You  have  probably  observed  that,  in  the  treatment  of  all  the  cases 
of  fever  that  came  before  me,  I  have  not  prescribed  altogether  a  dozen 
grains  of  calomel ;  that  I  have  very  seldom  ordered  any  kind  of  pur- 
gative medicine ;  that  I  have  been  sparing  in  the  use  of  leeches  and 
cupping,  and  that  I  have  not  ordered  a  single  patient  to  be  blooded. 
This  I  am  sure  will  appear  strange  to  the  various  sects  of  pathologists 
and  theorists  whom  I  have  seen,  Hke  so  many  waves  succeeding  each 
other,  and  whose  doctrines  were  equally  doomed  to  break  on  the  solid 
and  immovable  shore  of  truth.  I  recollect  how  each  doctrine  arose, 
and  made  converts,  and  influenced  practice ;  how  each  had  its  day,  and 
then  sank  into  that  obscurity  and  neglect  to  which  vain  and  profitless 
speculations  are  always  destined. 

I  recollect  when  it  was  the  custom  to  commence  the  treatment  of 
fever,  by  prescribing  ten  grains  of  calomel,  to  be  followed  by  a  bolus 
containing  fifteen  grains  of  jalap,  or  by  a  large  draught  composed  of 
infusion  of  senna,  epsom  salts,  and  electuary  of  scammony.  I  remem- 
ber the  time  when  it  was  the  fashion  to  bleed  every  case  of  fever  which 
came  into  hospital,  no  matter  what  the  stage  of  the  disease  might  be, 
or  what  the  condition  of  the  patient  was  at  the  time  of  admission.  I 
recollect,  too,  when  the  prostration  and  weakness  which  accompanies 
local  inflammation,  particularly  of  the  digestive  system,  used  to  be 
treated  with  wine  and  stimulants. 

Every  epidemic  is  peculiar  and  distinct  in  its  nature,  and  each  con- 
sequently requires  a  distinct  and  peculiar  mode  of  treatment.  Hence 
the  necessity  of  studying  fever  unbiassed  by  any  preconceived  notions, 
and  independent  of  the  trammels  of  dogmatism.  AVith  a  person  who 
observes  in  this  way,  who  studies  the  disease  as  it  is,  and  not  as  it  is 
described ;  whose  practice  is  regulated,  not  by  the  doctrines  of  the 
schools  but  by  the  results  of  investigation,  carefully  weighed  and  con- 
sidered :  with  such  a  person,  the  treatment  of  fever  will  be  simple  and 


CONCLUDING    REMARKS    ON    PEVEE.  279 

successful,  and  I  believe  that  there  is  no  disease  in  which  success  so 
much  depends  on  treatment  as  fever.  It  is  difficult  t©  explain  how  it 
came  to  pass  that  a  contrary  opinion  could  be  promulgated  in  Dublin. 
Something  must  be  attributed  to  the  neglect  or  incapacity  of  those, 
whose  duty  it  was  to  teach  the  truth. 

The  chief  cause  may,  however,  be  traced  to  the  activity  and  zeal 
which  inspired  some,  not  only  to  uphold  their  own  branch  of  the 
profession,  but  to  decry,  I  had  almost  said  to  defame,  that  which  they 
were  pleased  to  call  ][)ure  medicine.  With  characteristic  inconsistence, 
however,  these  gentlemen,  who  declared  that  the  treatment  of  fever  was 
at  best  useless,  readily  engaged  in  its  management  in  private  practice, 
and  while  they  professed  openly  their  disbelief  in  the  efficacy  of  any 
medicines,  they  busily  employed  themselves  in  prescribing  pills  and 
draughts  without  number  for  their  own  fever  patients.  That  -  they 
thought  their  treatment  of  some  value,  might  be  gathered  from  their 
acceptance,  their  invariable  acceptance,  of  pecuniary  remuneration  from 
the  sufferers'  grateful  friends,  who  little  dreamed  the  while  that  the 
hands  which,  with  automatic  movement,  so  readily  grasped  their  fees, 
belonged  to  persons  who  held,  nay,  who  maintained,  the  opinion  that 
the  treatment  of  fever  was  all  a  farce.  Posterity  will  scarcely  give  cre- 
dence to  this  fact,  and  will  probably  refuse  to  believe  that  such  an 
opinion  could  have  been  advanced  in  what  we  are  pleased  to  call  an 
enlightened  age,  and  an  enlightened  city.  They  will  scarcely  think  I 
speak  the  truth  in  assuring  them,  that  a  spirit  of  medical  intolerance 
existed  to  such  a  degree  at  the  time  of  the  discovery  of  the  stethoscope, 
that  whoever  in  Dublin  actively  occupied  himself  in  verifying  the  re^ 
searches  of  the  immortal  Laennec — whoever  availed  liimseK  of  the  new 
resources  invented  by  this  great  physician,  was  sure  to  become  an  ob- 
ject, not  merely  of  dislike,  but  of  animadversion  and  ridicule,  on  the 
part  of  those  who  ought  to  have  exerted  their  influence  in  endeavour- 
ing to  advance,  and  not  to  retard,  the  progress  of  science.  Happily 
for  the  character  of  the  country,  their  endeavours  have  been  frustrated, 
and  the  cause  of  truth  has  triumphed.  Happily  for  the  students  and 
their  future  patients,  those  teachers  are  now  most  followed,  who  best 
explain,  and  most  diligently  illustrate,  the  phenomena  observed  by  means 
of  mediate  auscultation. 


280 


LECTUEE  XXI. 


YELLOW  FEVER  OF  THE  BRITISH  ISLANDS. 

In  tlie  epidemic  of  1826^  we  had  several  cases  in  the  Meath  Hospital 
that  presented  all  the  characters  of  yellow  fever.  This  is  a  very  remark- 
able fact^  for  this  form  of  fever  has  been  very  rarely  witnessed  in  this 
country,  nor  does  it  seem  to  have  been  observed  in  any  part  of  Europe, 
to  the  north  of  Cadiz,  Gibraltar,  and  other  towns  of  Andalusia.  The 
last  epidemic  of  yellow  fever  in  Gibraltar  is  described  by  Louis,  who  with 
Trousseau  and  Cherrin  was  sent  by  the  Erench  government  to  investigate 
the  disease.  I  shall  quote  from  his  report  an  account  of  the  symptoms 
and  post-mortem  appearances  which  they  observed,  and  compare  it  with 
the  description  of  the  yellow  fever  of  1826,  printed  by  myself  and  Dr. 
Stokes,  for  the  use  of  the  pupils  of  the  Meath  Hospital. 

"  The  disease,"  says  Louis,  "  spared  neither  age  nor  sex ;  men  and 
women,  young  and  old,  were  alike  its  subjects.  Those  only  were  exempt 
from  its  influence,  who  had  been  affected  with  the  disease  in  a  former 
epidemic. 

"  It  commenced  at  different  hours  of  the  day^  sometimes  in  the  night, 
sometimes  fasting  or  soon  after  eating,  usually  with  an  intense  headache, 
accompanied  by  chills,  shivering,  pain  in  the  limbs,  and  soon  after  pain 
in  the  back.  A  heat,  rarely  intense,  succeeded  to  the  chills,  and  was 
sometimes  followed  by  perspiration.  At  the  same  time  the  countenance 
became  red  and  aniiliated ;  and  in  some  cases,  as  it  were,  swollen.  The 
eyes  were  red,  glistening,  suffused,  and  in  many  cases  the  patients  com- 
plained of  a  smarting  sensation  in  them.  The  thirst  was  intense,  the 
anorexy  complete.  It  was  rare  that  the  patient  suffered  any  pain  in  the 
epigastrium  at  this  period. 

"  The  first  symptoms,  the  headache,  the  pain  in  the  limbs,  the  anorexy, 
the  thirst,  the  heat,  the  redness,  and  the  pain  in  the  eyes,  continued  :  the 
headache  during  half  the  disease,  the  pains  in  the  limbs  a  little  longer, 


I 


YELLOW    FEVER.  281 

and  the  heat,  which  in  many  cases  was  but  sHghtly  increased,  continued 
so  during  nearly  the  same  time. 

"  The  pain  in  the  epigastrium,  so  rare  at  the  commencement,  came  on 
usually  fifteen  or  twenty  hours  later.  It  was  generally  inconsiderable, 
and  very  few  patients  complained  of  severe  or  acute  pain.  With  the 
epigastric  pain  came  the  nausea  and  vomitings,  excited  by  drinks  and 
purgatives  in  several  cases,  spontaneous  in  others.  The  dejections  were 
infrequent,  that  is  where  no  laxatives  had  been  administered.  The  ab- 
domen preserved  its  form,  was  supple  and  indolent,  except  in  the  epigas- 
tric region.  The  sleep  was  inconsiderable — some  patients  were  restless, 
in  some  there  was  a  good  deal  of  jactitation  during  the  night ;  others, 
and  the  smaller  number,  experienced  as  early  as  the  third  day,  a  real 
anxiety,  could  not  remain  quiet  in  any  posture,  and  in  some  cases  there 
was  deKrium.  But  this  symptom  did  not  usually  come  on  till  the  last 
day  of  life ;  and  for  this  reason  it  is  to  be  considered  rather  as  belonging 
to  the  agony  than  to  the  disease ;  otherwise,  with  few  exceptions,  there 
was  neither  prostration  nor  stupor.  The  pulse  was  moderately  accelera- 
ted, regular,  generally  bearing  relation  to  the  degree  of  heat,  which  was 
almost  always  slight,  as  I.  have  before  said.  The  skin  of  the  thorax  was 
injected  in  some  cases.  This  redness  and  that  of  the  eyes,  diminished 
toward  the  middle  period  of  the  disease,  or  a  little  later,  and  new  symp- 
toms appeared.  To  the  injection  of  the  integuments  of  the  chest  there 
succeeded  a  slight  yellow  tint  of  that  part,  and  the  eyes  were  the  same 
colour.  When  this  colour  appeared  thirty-six  or  forty-eight  hours  before 
death,  it  became  rapidly  brighter,  so  as  to  be  of  considerable  intensity  at 
the  time  of  the  fatal  termination.  In  other  cases  where  it  came  on  only 
just  before  death,  it  was  slight  at  the  autopsy,  and  commonly  limited  to 
the  trunk.  At  about  the  same  period,  or  a  little  later,  the  matter  vomited 
and  the  discharges  from  the  bowels,  which  up  to  that  time  had  presented 
notliing  remarkable,  took  on  a  certain  character,  wliich  they  have  not  in 
the  course  of  the  acute  diseases  of  Paris.  The  dejections  were  blackish 
or  blueish,  and  the  matter  vomited,  from  being  of  a  yellow  colour,  became 
brown  or  black.  At  the  commencement  of  this  change  of  colour,  the 
vomit  was  a  liquid  matter,  more  or  less  greyish,  mixed  with  a  greater 
or  less  quantity  of  mucus,  in  which  were  to  be  seen  blackish  particles, 
like  soot. 

"  At  this  period  of  the  disease,  the  uncomfortable  feelings  and  the 
anxiety  continued  during  different  lengths  of  time,  and  in  different  de- 
grees, the  strength  diminished,  the  temperature  fell,  so  .that  the  limbs 
were  cold  before  the  agony ;  in  a  certain  number  of  cases  there  was  a 
suppression  of  urine.  Sometimes  also  we  observed  a  sort  of  remission, 
an  apparent  amelioration  of  the  symptoms,  and  death  took  place  when  it 


282 


CLINICAL   MEDICINE. 


would  least  have  been  expected,  had  not  experience  taught  us  to  distrust 
this  deceitful  remission.  In  some  subjects  the  violence  of  the  headache, 
that  of  the  pains  of  the  limbs,  the  marked  febrile  symptoms,  the  numerous 
vomitings,  the  uncomfortable  feelings,  the  anxiety,  the  bright  redness  of 
the  eyes,  gave  to  the  disease  a  truly  serious  aspect ;  whilst  in  others  the 
mildness  of  the  fever,  and  of  the  pains  wherever  seated,  the  absence  of 
agitation  and  delirium,  the  shght  diminution  of  the  strength,  impressed 
on  the  disease  a  character  of  mildness,  calculated  to  deceive  at  once  the 
patients,  their  attendants,  and  the  physician.  It  is  under  this  form  of 
the  disease  that  patients  died  without  taking  to  their  beds — on  foot,  as 
it  was  expressed  by  their  friends.  Thus  Dr.  Mathias,  who  died  after  an 
illness  of  four  or  five  days,  experienced  no  other  symptoms  but  severe 
pains  in  the  calves  of  the  legs,  and  a  suppression  of  urine.  He  had  no 
nausea ;  he  did  not  vomit ;  his  mind  was  perfectly  clear  during  the 
whole  course  of  the  disease. 

"  This  kind  of  latent  condition  of  the  yellow  fever  does  not  distinguish 
it  from  the  acute  diseases  of  Paris,  which  also  are  often  obscure,  and 
their  symptoms  mild ;  but  it  is  remarkable  on  account  of  the  rapid  pro- 
gress of  the  disease,  usually  fatal  from  the  fourth  to  the  sixth  day.  And 
this  latent  form  reminds  us  at  once  of  certain  facts  of  poisoning  by  arsenic, 
in  instances  of  individuals  who  have  retained  their  clearness  and  calm- 
ness of  mind,  from  the  moment  of  swallowing  the  poison  until  their 
death. 

"  I  add,  that  the  severity  of  the  symptoms  does  not  correspond  always 
with  that  of  the  lesions.  Of  these  last,  one  only  was  constant,  the  spe- 
cific alteration  of  .the  Hver.  The  inflammatory  state  of  the  mucous 
membrane  of  the  stomach  comes  next  in  frequency,  and  sometimes  ex- 
plains in  a  manner  sufficiently  satisfactory  the  symptoms  that  had  been 
observed.'^ 

The  following  are  the  appearances  which  Louis  found  in  the  fatal 
cases  of  yeUow  fever  at  Gibraltar : — "^ 

"  The  stomach  was  larger  than  natural  in  seven  subjects,  smaller  than 
usual  in  three.  It  contained  a  clear  or  dark  red  coloured  liquid,  a  black- 
ish or  perfectly  black  fluid,  in  different  quantities,  in  three  quarters  of 
the  cases.  Its  mucous  membrane  was  red,  through  a  greater  or  less 
extent,  in  six  cases ;  rose  coloured  or  orange  in  eight  cases ;  greyish, 
yellowish,  or  whitish  in  the  others.  It  was  thickened  through  a  greater 
or  less  extent  of  surface  in  half  the  cases ;  softened  and  yellow  to  an 
extreme  degree  in  the  same  number ;    at  the  same  time  thickened. 


*  I  have  intenlionally  omitted  the  very  minute  description  of  the  thoracic  viscera,  the 
brain,  spinal  cord,  &c. ;  suffice  it  to  say,  there  was  nothing  observed  worthy  of  note. 


YELLOW   FEVER.  283 

softened,  and  red  in  a  tliird  part  of  tlie  cases ;  mamelonated  in  two- 
thirds  ;  ulcerated  in  two  cases ;  and  natural  in  five  cases. 

"  The  mucous  membrane  of  the  duodenum  was  red  in  a  little  more 
than  half  of  the  cases ;  softened  in  the  same  number  \  and  thickened 
in  one  case. 

^'  The  small  intestines  contained  a  greater  or  less  quantity  of  reddish, 
brownish,  blackish,  or  perfectly  black  matter,  in  two-thirds  of  the  cases. 
Its  mucous  membrane  was  slightly  injected  or  red  in  spaces,  in  a  little 
less  than  half  the  cases.  Its  consistence  was  more  or  less  diminished 
through  its  whole  length,  or  through  a  part  of  its  extent  only,  in  rather 
a  greater  number  of  cases.  It  was  partially  thickened  in  one  case ;  in 
no  case  was  it  ulcerated ;  and  Peyer's  glands  were  always  natural. 

"  The  large  intestine  w^as  of  greater  size  than  usual  in  two  cases.  In 
fifteen  cases  it  contained  a  matter  of  a  wine  lees  colour,  or  blackish,  or 
brownish,  or  chocolate  coloured,  or  entirely  black.  Its  mucous  mem- 
brane was  of  a  pale  or  bright  red  colour  in  five  cases ;  greyish,  yellowish, 
or  whitish  in  the  others.  Its  consistence  was  more  or  less  diminished 
in  three  fourths  of  the  subjects.  Its  thickness  was  increased  in  three 
cases ;  and  twice  we  found  it  slightly  ulcerated. 

"The  mesenteric  glands  presented  traces  of  inflammation  in  four 
cases ;  the  cervical  glands  in  one  case ;  in  another  case  one  of  the  glands 
above  the  Uliary  ducts  was  red,  softened,  and  very  large. 

"  The  live7'  was  of  greater  size  than  natural  in  tw^o  cases ;  a  little 
firmer  than  usual  in  three  cases;  a  little  less  firm  in  three  others.  Its 
cohesion  was  increased  in  six  cases,  diminished  in  seven.  Its  colour 
VMS  altered  in  every  case,  sometimes  it  was  of  the  colour  of  fresh  butter, 
sometimes  of  a  straw  yellow,  a  clear  coffee  and  milk  colour,  sometimes  a 
gum  yellow,  sometimes  of  an  orange  colour. 

"  The  spleen  was  softened  in  eight  cases,  and  to  a  moderate  degree, 
with  one  exception.     It  was  larger  than  usual  in  five  cases. 

"The  lesions  which  we  have  thus  placed  before  the  reader,  were 
rarely  considerable,  very  often  insufficient  to  exjolain  the  death,  and 
when  this  explanation  was  afi*orded,  it  w^as  by  a  combination  of  several 
lesions. 

"These  lesions  may  be  divided  into  tw^o  classes,  some  of  them  peculiar, 
or  almost  exclusively  pecuhar,  to  subjects  dying  of  yellow  fever ;  others 
common  to  those  subjects,  and  to  subjects  who  have  died  of  other  acute 
diseases.  The  red  or  black  matter  found  in  the  alimentary  canal,  and 
the  remarkable  alteration  of  the  liver,  are  of  the  first  class,  all  the  other 
lesions  of  the  second. 

"  The  red  or  black  matter  of  the  stomach  or  intestines  not  having 
been  found  in  all  the  cases  of  yellow  fever,  it  cannot  be  considered  an 


284  CLINICAL   MEDICINE. 

anatomical  character  of  the  disease.  But  it  is  not  so  with  the  alteration  of 
the  liver y  which  was  more  or  less  exactly  the  same  in  all  the  cases,  and 
which,  for  that  reason,  ought  to  be  considered  as  the  essential  anato- 
mical character  of  the  yellow  fever  of  Gibraltar,  of  1828. 

"  Amongst  the  lesions  of  the  second  class,  the  yellowness  and  the 
inflammation  of  the  mucous  membrane  of  the  stomach  should  be  espe- 
cially remarked,  as  well  from  their  frequency  as  on  account  of  the  rapi- 
dity with  which  they  come  on.  The  inflammation  of  the  mucous  mem- 
brane of  the  stomach  not  having  taken  place  in  all  the  cases,  and  Peyer's 
glands  not  having  ceased  to  be  natural,  it  follows  on  the  one  hand,  that 
the  yellow  fever  of  Gibraltar,  of  1828,  is  not  a  gastritis,  and  on  the 
other  hand,  that  it  is  not  a  typhoid  fever.  This  last  conclusion  is  even 
more  strict ;  for  not  only  was  there  an  absence  of  the  lesions  of  typhoid 
fever  in  the  bodies  of  the  victims  of  yellow  fever,  but  these  bodies  pre- 
sented other  lesions  which  are  not  found  in  the  victims  of  the  first  dis- 
ease, and  which  are  peculiar  to  the  second  disorder. 

"What,  then,  is  the  nature  of  the  yellow  fever  of  Gibraltar,  of  1828, 
and  where  is  the  seat  of  it  ?  If  it  be  neither  a  gastritis  nor  a  typhoid 
fever,  neither  is  it  a  hemorrhage,  as  it  has  lately  been  said  to  be,  for 
the  hemorrhage  did  not  take  place  in  all  cases.  Is  it  a  disease  of  the 
liver  ?  Undoubtedly  the  liver  was  the  organ  principally  and  essentially 
affected ;  still  we  cannot  regard  the  yellow  fever  as  simply  a  disease  of 
the  liver,  because  its  lesion,  at  least  in  the  present  condition  of  science, 
does  not  explain  the  febrile  symptoms  in  the  cases  where  tliis  was  the 
only  lesion ;  and  in  the  second  place,  because  it  is  entirely  insufficient 
to  explain  the  death. 

"  As,  then,  a  strict  analysis  of  the  anatomical  appearances  of  the  yel- 
low fever  of  Gibraltar,  of  1828,  proves  the  existence  of  a  cause  unequal 
in  its  operation,  and  of  which  but  one  effect  is  constant,  the  specific 
alteration  of  the  liver,  and  as  in  a  third  part  of  the  cases,  it  is  directly 
to  this  cause  that  we  are  obliged  to  refer  the  death,  we  naturally  ask 
how  does  this  act,  through  the  medium  of  wliat  system  does  it  exert  its 
influence  on  the  economy  ?  Is  it  through  the  nervous  system,  is  it 
tln-ough  the  blood,  in  which,  however,  we  have  not  detected  any  especial 
modifications  ?" 

Let  us  now  compare  with  this  description  the  epidemic  I  witnessed 
in  Dublin,  in  1826.  The  first  case  I  shall  speak  of  is  that  of  John 
Gall,  aged  35.  Admitted  about  the  10th  January.  Date  of  illness 
unknown ;  probably  about  seven  or  eight  days.  Tenderness  of  epigas- 
trium chief  symptom,  and  with  it  costiveness ;  skin  hot ;  tongue  very 
dry  and  brown  in  centre,  edges  white,  a  little  moist ;  much  debihty  ; 
appeared  stupid,  but  no  delirium ;  memory  uncertain ;  at  one  time  he 


YELLOW   FEVER.  285 

said  lie  was  two  clays  ill;  at  another  for  several;  belly  hard,  full. — 
Leeches  to  epigastrium,  and  purgatives  ivith  apparent  relief. — Next 
day  he  got  effervescing  draughts,  and  began  to  complain  of  cough. — 
Blister  on  the  chest  on  the  following  day. — That  night  he  became 
yellow,  being  convulsed  in  the  abdominal  muscles,  and  died  at  5  a.m. 
yesterday. 

Dissection  30  hours  after  death. — Body  well  made,  strong,  muscular; 
skin  and  conjunctivae  yellow ;  posterior  parts  livid.  Dura  mater  yel- 
low ;  no  fluid  between  dura  mater  and  arachnoid ;  considerable  quantity 
of  fluid  under  arachnoid,  between  convolutions,  of  amber-yellow  colour ; 
brain  remarkably  firm;  substance  white;  yellow  fluid  in  right  ven- 
tricle and  also  in  left,  in  anterior  cornua  in  considerable  abundance,  par- 
ticularly in  left. — Abdomen.  Liver  natural ;  no  obstructions  in  ducts ; 
bile  in  gall-bladder ;  stomach  of  a  dark  purple  colour  universally  ;  mu- 
cous membrane  increased  in  thickness  ;  bleeds  when  torn ;  is  evidently 
a  little  softened;  villous  coat  like  velvet;  when  in  water  villosities 
whitish  and  floating.  Near  the  pylorus  we  observed  a  very  curious 
and  beautiful  appearance ;  the  mucous  membrane  was  here,  as  in  other 
parts,  of  a  purplish-red  colour,  marked  in  many  places  by  rings  of  a 
white  colour,  and  perfectly  circular,  and  about  half  an  inch  in  diameter. 
These  rings,  formed  by  a  circle  about  half  a  line  in  breadth,  included  a 
space  purple  like  the  rest  of  the  mucous  membrane  ;  and  in  many  places 
intersections  of  these  white  circles  were  observed  :  white  serpentine  lines 
were  also  apparent  in  this  part  of  the  stomach.  On  placing  the  sto- 
mach in  water,  we  discovered  that  these  white  circles  and  serpentine 
lines  were  formed  by  the  extremities  of  villous  processes,  which  had  not 
a  purple  colour  like  the  rest.  Duodenum  was  also  red,  but  the  redness 
decreased  gradually.  One  intussusception,  including  a  portion  of  in- 
testine six  inches  in  length,  was  found  in  the  small  intestines.  The  in- 
vaginated  portion  of  intestine  was  easily  withdrawn  from  within  that 
v)hich  had  enclosed  it,  and  there  was  not  the  slightest  mark  of  inflam- 
matio?i  in  either. 

This  is  a  good  example  of  the  morbid  appearances  exhibited  by  those 
fatal  cases  of  fever  which  had  been  so  frequent  in  the  epidemic  of  1826. 
We  lost  nearly  twenty  patients,  in  whom  the  symptoms  ran  nearly  the 
course  above  detailed.  In  all,  the  abdomen  became  hard  and  tender 
about  the  epigastrium  and  hypochondria,  and  often  without  any  pre- 
monitory symptoms  indicative  of  the  approaching  danger.  This  hard- 
ness and  knotted  feel  of  the  abdominal  muscles,  was  followed  by  an 
appearance  of  general  jaundice  of  a  bright  yellow  colour,  accompanied  by 
uneasiness  and  anxiety  of  countenance,  a  very  quick  and  hurried  pulse 
and  coldness  of  extremities.     Death  generally  took  place  in  such  cases 


286  CLINICAL   MEDICINE. 

within  twentj-four  hours  from  the  appearance  of  the  jaundice,  and  was 
preceded  in  some  cases  by  general  convulsions  (as  was  reported,  but  we 
ourselves  did  not  observe  any  general  convulsions) ;  in  most,  by  spasms 
limited  to  the  abdomen,  and  which  obtained  among  the  nurses  the 
appropriate  name  of  "  Twisting  of  the  Guts,''  a  name  which  agrees 
singularly  with  the  intestinal  intus-susceptions  found  in  almost  all. 
Before  entering  into  the  subject  of  the  pathology  of  this  singular  form 
of  fever,  I  shall  detail  a  few  more  examples  of  it. 

John  Rochford,  aged  50,  was  admitted  into  shed  No.  4,  with  low 
fever ;  became  convalescent  after  a  few  days  without  any  regular  crisis ; 
appetite  returned,  and  he  continued  well  for  about  six  days,  when  he 
relapsed.  Belly  a  little  hard,  and  tender  to  the  touch ;  complained  only 
of  costiveness ;  some  purgative  medicine  was  directed,  which  not  having 
the  desired  effect,  an  oil  draught  was  prescribed,  and  having  operated 
freely,  patient  appeared  much  relieved  at  next  visit ;  but  between  11 
and  12  p.m.  was  seized  with  convulsions  of  beUy,  but  not  of  extremities ; 
suddenly  became  jaundiced,  and  died  next  morning.  The  tip  of  his 
nose  became  of  a  deep  purple  colour.  The  friends  having  taken  away 
the  body,  we  had  not  an  opportunity  of  examining  the  morbid  appear- 
ances. 

We  have  had  several  cases  in  wliich  the  nose  became  purple  in  fever, 
and,  with  one  exception,  they  all  proved  fatal.  Wlien  the  purple  nose 
is  combined  with  general  jaundice,  the  patient  presents  a  truly  frightful 
appearance ;  this  has  happened  in  five  or  six  instances.  Sometimes  the 
purple  colour  is  limited  to  the  tip  of  the  nose,  while  in  other  cases  it 
spreads  from  the  nose  to  the  upper  portion  of  the  cheeks.  The  parts 
about  to  become  purple  assume  at  first  a  pale  appearance ;  this  paleness 
is  gradually  converted  into  a  livid  leaden  hue,  and  the  part  becomes 
quite  purple,  generally  in  the  course  of  12  or  24  hours.  It  is  to  be  ob- 
served, that  the  parts  thus  affected  preserve  their  natural  heat  until 
shortly  before  death,  when,  of  course,  the  tip  of  the  nose  is  among 
the  first  parts  to  grow  cold.  In  the  case  of  a  girl  in  shed  No.  2,  whose 
nose  and  cheeks  became  purple,  this  change  took  place  more  slowly  than 
usual.  At  first  the  parts  were  observed  to  be  covered  with  broad  patches 
of  a  wax-like  whiteness,  somewhat  elevated  above  the  surrounding  sur- 
face, which  so  much  resembled  urticaria  that  it  was  considered  to  ap- 
proach, in  its  nature,  to  that  eruption;  the  following  day,  however, 
these  spots  were  found  to  have  become  of  a  red  colour,  and  on  the  next 
day  the  redness  was  converted  into  a  deep  purple.  During  the  whole 
of  this  time  the  heat  of  these  parts  was  not  less  than  that  of  the  rest  of 
the  body.     She  died  on  the  following  day. 

In  the  case  of  a  woman  also  in  slied  No.  2,  in  whom  the  tip  of  the 


YELLOW   FEVER.  287 

nose  and  the  ends  of  some  of  the  toes  became  purple,  these  parts  were 
tender  to  the  touch ;  this  woman  recovered.  Leeches  were  applied  to 
the  tip  of  the  nose,  and  tepid  stupes  or  poultices  kept  constantly  applied 
to  the  discoloured  j)arts ;  a  small  portion  of  the  nose  separated  and  came 
away  in  the  form  of  a  slough.  These  facts  prove  that  this  purple  colour 
of  the  nose  and  other  parts,  in  many  instances^  at  least,  arises  from  a 
condition  of  the  vascular  system  of  these  parts  closely  aUied  to  inflam- 
mation. We  possess  a  drawing  of  a  patient  in  whom,  from  the  effects 
of  cold,  the  tops  of  the  fingers  became  purple  and  excessively  tender 
when  exposed  even  to  the  common  temperature  of  the  wards  in  winter. 
Great  rehef  from  pain,  and  some  diminution  of  intensity  in  the  colour 
was  obtained  by  keeping  the  fingers  immersed  in  tepid  water.  This  case, 
which  was  treated  by  Mr.  M'Namara,  had  lasted  for  some  weeks  before 
admission,  and  yielded,  but  not  until  the  lapse  of  a  considerable  time,  to 
the  employment  of  tepid  applications,  &c. 

Patrick  Mahon,  aged  45,  a  stone-cutter,  st:fong  habit.  Admitted  into 
shed  No.  4,  labouring  under  fever  of  a  typhoid  character.  Tongue 
loaded  -,  teeth  covered  with  sordes ;  abdomen  hard ;  tenderness  of  epi- 
gastrium and  hypochondria  on  pressure ;  complained  of  weakness. — 
Twenty  leeches  were  applied  to  the  epigastrium,  and  Purgative  Injections 
administered. — Tlie  following  morning  the  skin  and  conjunctiva  appeared 
slightly  yellow.  Abdomen  still  hard ;  pulse  weak  and  quick ;  much 
debihty. —  Was  ordered  some  Bkce  Fill,  and  to  repeat  the  Injections. — 
At  the  next  visit,  the  yellow  colour  continuing,  the  abdomen  being  still 
hard,  and  the  epigastrium  tender,  twenty  leeches  were  again  apphed,  and 
the  former  medicines  repeated.  At  4  o^ clock  in  the  evening  was  seized 
with  convulsions,  and  died  early  next  morning.  The  convulsions  only 
appeared  to  affect  the  abdomen. — Body  not  examined. 

John  Gaven,  aged  22.  This  man^s  case  differed  in  no  material  cir- 
cumstances from  the  preceding  cases. — Dissection  20  hours  after  death. 
Body  extremely  well  made,  strong,  and  muscular.  Nothing  morbid  in 
head  or  thorax,  except  dilatation  of  some  bronchial  tubes. — ^Abdomen  : 
Five  hitiis-susceptions  in  small  intestines,  without  any  adhesion  or  marks 
of  recent  injlammation ;  other  parts  of  the  intestines  considerably  con- 
tracted; mucous  membrane  of  stomach,  from  cardiac  orifice  to  within 
about  two  inches  of  the  pylorus  of  a  brownish-red  colour.  Here  the 
mucous  membrane  yields  readily  to  the  back  of  the  knife,  and  may  be 
scraped  off  in  a  semi-fluid  state ;  it  contains  several  patches  of  ecchymosis. 
The  whole  of  the  intestinal  tube,  with  the  exception  of  the  duodenum 
and  the  lower  half  of  the  large  intestines,  has  its  mucous  membrane  of  a 
dark  red  colour,  with  numerous  ramifications  of  vessels '  engorged 
with   blood.      In   many  parts   the   mucous  membrane  is    very   soft. 


288  CLINICAL   MEDICINE. 

and  almost  semi-fluid.       Liver  perfectly  healthy :    no   obstruction  in 
gall-ducts. 

As  time  will  not  permit  me  to  detail  more  dissections  of  this  truly 
curious  and  fatal  form  of  fever,  I  shall  merely  sum  up  some  of  the  prin- 
cipal points  connected  with  its  pathology.  1st.  In  none  did  we  find 
inflammation  of  the  liver,  or  obstruction  of  the  gall-ducts.  2dly.  In 
all,  evident  marks  of  inflammation  were  found  in  the  mucous  membrane 
of  the  stomach,  such  as  redness,  softness,  &c.  3dly.  In  almost  every 
instance  we  found  one  or  more  intus-susceptions  in  the  small  intestines. 
4thly.  All  these  were  without  any  mark  of  inflammation  of  the  serous 
membrane,  and  the  invaginated  portion  of  the  intestine  could  be  always 
easily  drawn  out  of  the  other.  5thly.  In  several  we  found  effusion  of  a 
yellowish  or  amber  coloured  fluid  between  the  arachnoid  and  pia  mater, 
at  the  base  of  the  brain,  and  sometimes  in  the  ventricles,  but  in  these 
only  in  small  quantity.  6thly.  In  none  did  we  find  inflammation  of  the 
brain  or  its  membranes.  7thly.  "We  found  the  spleen  very  much  enlarged 
in  almost  all.  When  the  spleen  in  acute  diseases  is  thus  engorged  and 
distended,  it  is  invariably  softer  than  natural.  In  but  one  case  did  we 
find  a  considerable  quantity  of  a  dark  red  fluid  in  the  stomach,  together 
with  a  good  deal  of  a  substance  resembling  coffee  grounds,  and  in  this 
case  the  mucous  coat  of  the  stomach  was  in  many  places  of  a  very  dark 
colour,  and  a  slimy  consistence,  so  that  there  could  be  but  little  doubt 
concerning  the  origin  of  the  contained  fluid,  and  the  coffee-grounds  sub- 
stance, which  must  have  proceeded  from  the  diseased  and  almost  disor- 
ganised mucous  membrane.  Such  have  been  the  principal  appearances 
observed  during  the  dissection  of  about  fifteen  fatal  cases  of  fever  com- 
bined with  yellowness  of  the  skin.  The  following  cases  will  convey  a 
more  exact  idea  of  the  symptoms  which  characterise  this  form  of  fever 
than  those  already  related,  which  proved  too  suddenly  fatal  to  allow  a 
full  development  of  the  symptoms. 

Peter  Kelly,  aged  28,  on  the  29th  December  was  admitted  into  No. 
4  fever  shed,  stated  that  for  two  days  previously  he  had  severe  cough 
without  expectoration.  Pulse  110,  strong;  face  flushed.  Tongue 
white,  moist ;  pain  across  forehead,  and  general  distress ;  great  tender- 
ness of  epigastrium  and  right  hypochondrium  ;  costive  ;  thirsty ;  abdo- 
men hard  :  on  examination  no  morbid  rale  was  perceptible ;  respiratory 
murmur  natural. — 30th  Dec.  Vencesectio  ad  Bxv.  Hirudines  xx  epigas- 
trio.  PilidcB  purg antes  et  mistura  purgans. — 31st.  Cough  very  severe. 
Vesicatorimn  pectori.  Mistura  pectoralis. — 1st  January,  1827.  Dur- 
ing last  night  became  jaundiced ;  considerable  distress  this  morning  ; 
black  stools  ;  great  tenderness  of  epigastrium  and  right  hypochondrium ; 
cough  very  troublesome.     Vencesectio  ad  Sxii.     Hirudines  xxx.  h/i 


YELLOW    FEVER.  289 

chmidrio  et  epigastrio.  Ahradantur  capilli  et  applicetur  vesicatorium 
veriici.  Swnat  oynni  hord  calomelanos  grana  duo, — 2d  January.  Mucli 
relieved ;  skin  not  nearly  so  yellow ;  tenderness  greatly  diminished ; 
some  sweat  last  niglit.  Bepetantur  Pilulce. — 3d.  Considerably  im- 
proved; skin  nearly  natural. — 4tli.  Mouth.  Affected  with  mercury; 
skin  natural.  Omittantur  medicamenta. — 5th.  Eemoved  to  convalescent 
ward. — 7th.  Convalescence  continues,  having  now  no  complaint  but 
shght  soreness  of  mouth. 

Here  the  yellow  colour  appeared  about  the  5th  day,  and  sweat  at- 
tended with  much  relief  on  the  7th  day.  The  symptoms  chiefly  worthy 
of  notice  are,  the  violence  of  the  febrile  reaction,  pain  of  forehead,  great 
tenderness  of  epigastrium  and  right  hypochondrium ;  blackness  of  stools, 
and  hardness  of  the  belly.  We  shall  just  now  see  the  great  importance 
of  these  symptoms  in  determining  the  true  nature  of  the  disease. 

January  14th. — Thomas  Kearney,  aged  38,  labourer ;  has  been  ill 
for  eiglit  days ;  was  first  attacked  with  rigor  and  pains  of  loins  and 
limbs,  which  still  continue.  He  also  complains  of  cough  and  pain  of 
chest ;  head  first  attacked  on  fifth  day ;  was  taken  into  hospital  the  fol- 
lowing day ;  got  some  purgative,  which  operated  powerfully.  Present 
symptoms.  Skin  dry  and  hot ;  eyes  and  skin  yellow ;  great  pain  of 
head ;  tongue  dry  and  white;  pulse  60  ;  the  colour  of  stools  very  dark  ; 
epigastrium  tender. — January  15th.  Ajoplicenhtr  Ilirudines  xx.  epigas- 
trio, et  vesicatorizim  pectori.  5j  Pilula  Hydrargyri,  gr.  ix.  ;  Extracti 
Hyoscyamiy  gr.  vi.  M.  in  pilulas  tres  divide.  Sumat  i.  ter  in  die.  Haheat 
hanstus  effervescentes  cum  Carhonate  AmmonicB^  et  enema  emolliens  ves^ 
pere. — Jan.  16.  Pain  of  chest  and  cough  removed,  and  pain  of  epigas- 
trium diminished  since  the  application  of  leeches,  which  stiU  continue 
bleeding :  ordered  to  be  stopped  by  the  appKcation  of  caustic ;  tongue 
moist;  looking  like  mercurial  ointment;  pulse  60,  strong;  coun- 
tenance much  improved ;  stools  much  more  natural ;  yellowness  nearly 
gone ;  sweated  much.  Repetantur  Filulce  Hydragyri  et  Extracti  Ilyos- 
cyami. — January  17th.  No  fever;  yellow  colour  quite  gone;  many 
loose  stools.     Omittantur  medicamenta. — January  18th.  Convalescent. 

The  state  of  the  pulse  in  this  case  was  remarkable.  It  did  not  ex- 
ceed 60,  at  a  time  when  the  existence  of  many  other  symptoms  left  no 
doubt  of  the  febrile  and  inflammatory  nature  of  the  complaint. 

December  30th,  1826.  Esther  McQuillan,  aged  33.  Complains  of 
general  pains  :  has  been  subject  to  violent  pains  for  the  last  three  years, 
after  having  laboured  under  fever  in  Cork- street  Hospital ;  was  there 
also  about  four  months  ago,  and  was  discharged  cured.  Present  state. 
Great  headache ;  tongue  brown  in  centre ;  pulse  small  and  weak ;  great, 
tenderness  of  abdomen  on  pressure;  bowels  very  free;  blooded  last 

VOL.  I.  19 


&90  CLINICAL   MEDICINE. 

night  for  cough  and  stuffing  of  chest ;  finds  herself  much  relieved  ; 
blood  slightly  buffed,  no  separation  of  serum ;  respiratory  murmur  na- 
tural ;  complains  of  pain  across  her  back. — Applicentur  Hirudines  xx. 
epigastrio. — December  31st.  Tongue  parched,  furred,  and  brown  in 
centre ;  tenderness  of  epigastrium  still  remains,  but  much  diminished ; 
is  very  slightly  jaundiced;  leech-bites  bled  well;  pulse  100,  regular; 
great  thirst ;  pains  of  joints  and  small  of  back  excessive,  and  prevent- 
ing motion  in  bed ;  breathing  free ;  urine  very  light  coloured. — E.  Nu 
trails  Potassa,  3ij.  Becocti  Hordei,  Ib.ii.  Acidi  Nitrici  Liluti,  3i.  Misce, 
consumatur  in  die. — January  1st,  1827.  Colour  more  yeUow;  great 
tenderness  of  epigastrium  and  right  hypochondrium ;  pains  as  before ; 
fever  unabated. — Habeat  Calomelanos,  gr.iij.  Opii,  gr.  |,  ter  in  die; 
Mistura  Camphor (b,  Sj.  ter  in  die, — January  2d.  Pulse  72,  weak,  at 
times  almost  imperceptible  but  regular ;  respiration  easy ;  yellow  stools, 
passed  under  her  ;  belly  very  tense ;  abdominal  muscles  contracted  and 
hard ;  tongue  black  and  parched ;  raves,  but  is  sensible  when  spoken 
to ;  lies  on  side.  Mepetantur  Tilula  et  Mistura  ;  Applicetur  Vesicato- 
Hum  HypocJiondrio.  Vini,  Bvi. — January  3d.  A  good  deal  of  cough ; 
raves  continually ;  yellowness  deeper  ;  many  yellowish  stools  passed 
under  her;  debility  much  increased;  tliirst  continues;  tongue  black 
and  parched ;  heat  natural ;  tremor ;  pulse  84  ;  blister  rose  but  little ; 
deglutition  impeded  by  a  spasm ;  just  before  visit  was  seized  with  a  fit, 
attended  with  spasms  and  rigidity  of  joints,  which  lasted  about  a 
minute ;  feet  cold. —  Vini  Rubri,  5vj.  Apjplicentur  sinapismi  jpedibus  ; 
Jtejpetatiir  Mistura  CaynpJiorce. 

January  4th.  Sensible  when  spoken  to  ;  puts  out  tongue  when 
desired ;  but  at  all  other  times  raving ;  seems  to  suffer  extremely  when 
joints  are  moved;  frequent  tremor  and  shuddering;  rested  scarcely 
any ;  other  symptoms  as  yesterday ;  some  swelling  of  ankles. — Appli- 
centur  Vesicatoria  suris.  Vini  ^vi. — January  5th.  Moaning  and  raving 
during  the  whole  night ;  no  vomiting ;  cough  looser ;  slept  a  little  this 
morning;  stools  yellow;  tongue  parched;  blisters  rose  well;  drinks 
abundantly ;  less  yellowness ;  no  headache ;  eyes  suffused ;  pulse  84, 
scarcely  to  be  felt,  regular ;  no  coldness  of  extremities ;  flatulence. — 
Uepetatur  Vinwn. — January  6th.  Slept  well ;  no  raving ;  countenance 
improving ;  fever  much  diminished  in  every  respect. — January  7th. 
Tongue  clean ;  pulse  80,  stronger  than  before ;  a  large  purple  spot  not 
elevated  occupies  the  whole  of  the  outside  of  right  instep ;  it  is  in 
some  places  vesicated;  appetite  good;  slept  well;  smaller  spots  on 
other  foot ;  camphorated  spirit  to  be  apphed  to  spots. — Habeat  SuU 
phatis  Quince  granum  ter  in  die. — January  8th.  Edges  of  large  spot 
more  vesicated ;  whole  surface  has  a  redder  and  less  purple  colour ; 


YELLOW   FEVER.  291 

three  stools  during  night;  little  sleep. — Bepetantur  Fihda  Sulpkatis 
Quince  et  Vinum.  January  9th.  Redness  of  right  eye,  not  painful ; 
foot  better. — Applicentur  Einidines  ii.  conjunctivce, — January  10th. 
Convalescent ;  remained  for  about  a  week,  and  was  discharged  cured. 

The  symptoms  of  this  case  were  very  alarming ;  so  much  so  indeed 
that  on  the  2d  and  3d  of  January  we  had  little  expectation  of  her  re- 
covery. At  this  period  the  involuntary  discharge  of  stools,  the  extreme 
weakness  of  pulse,  black  parched  tongue,  general  debility,  raving,  tre- 
mors, spasmodic  affection,  which  supervened  when  she  attempted  to 
swallow,  and  finally,  the  hard  and  hnotted  state  of  the  abdominal  mus- 
cles, together  with  a  fit  of  general  tonic  spasms ;  all  these  symptoms, 
combined  with  the  yellow  colour  of  the  skin,  rendered  her  recovery 
very  improbable.  The  treatment  was  in  the  commencement  antiphlo- 
gistic. The  nitre  was  prescribed  in  order  to  relieve  the  rheumatic 
pains ;  but  on  the  following  day  it  was  abandoned,  and  a  preference 
given  to  calomel  and  opium  for  obvious  reasons.  Nitre  does  not  act 
favourably  in  cases  where  much  debility  is  present,  or  where  the  stomach 
is  weak. 

In  several  of  the  cases  attended  with  jaundice  which  proved  fatal, 
the  symptoms  were  very  similar  to  those  described.  The  case  of 
McQuillan  may  be  looked  on  as  presenting  a  good  example  of  this  pecu- 
liar species  of  fever.  In  her  case,  as  well  as  in  several  of  the  fatal 
cases,  the  alvine  discharges  were  of  a  healthy  colour ;  and  in  several  of 
the  latter  the  Hie  found  in  the  gall-bladder  after  death  was  in  its  pro- 
perties quite  statural.  About  one-half  of  the  persons  so  affected  raved, 
betrayed  great  restlessness,  and  their  countenance  had  a  pecuHar  ex- 
pression of  anxiety ;  others  seemed  in  perfect  possession  of  their  intel- 
lectual faculties  to  the  last,  but  at  the  same  time  appeared  in  a  most 
nervous,  irritable,  and  desponding  state  of  mind.  They  could  not  rest 
for  a  moment  tranquil,  but  tossed  their  arms  about,  and  regarded  their 
attendant  with  a  look  expressive  at  once  of  nervous  suffering  and 
despair.  Many  vomited  very  often ;  aU  complained  of  extreme  tender- 
ness of  the  epigastrium. 

Here  I  may  observe,  that  in  the  epidemic  of  1826  we  opened 
many  bodies,  in  wliich  peritoneal  inflammation  might  have  been  ex- 
pected, judging  from  the  extreme  epigastric  and  abdominal  tenderness 
during  life ;  and  yet  we  found  no  marks  of  peritonitis  whatsoever. 
The  large  purple  spot  in  the  instep  seemed  at  first  of  a  similar  nature 
with  the  purple  colour  of  the  nose  and  lips  before  described  ;  it  proved 
however  to  be  erysipelas,  and  ended  in  vesication.  It  differed  from 
common  erysipelas  in  its  dark  livid  purple  colour,  and  in  having  a  well 
defined  abrupt  boundary,  and  in  the  colour  disappearing  but  little  on 


292  CLINICAL   MEDICINE. 

pressure.  In  fact,  it  seemed  to  be  as  it  were  intermediate  between 
purpura  and  erysipelas.  The  advantage  of  wine  and  stimulants  towards 
the  conclusion  of  this  fever  was  very  apparent. 

January  15,  1827. — Robert  Parmer,  aged  19.  Has  been  ill  five 
days ;  was  employed  in  a  brewery,  where  he  was  exposed  to  hot  steam, 
producing  a  copious  perspiration,  during  which  he  drank  a  great  quan- 
tity of  cold  beer;  was  immediately  seized  with  a  violent  rigor  and 
fulness  of  head ;  the  rigor  lasted  for  an  hour ;  a  comparative  calm  en- 
sued. The  head,  however,  still  continued  uneasy;  loss  of  appetite 
followed ;  but  he  endeavoured  to  w  ork  for  two  or  three  days,  when  he 
was  obhged  to  remain  in  bed ;  has  been  in  a  violent  heat  since,  unless 
he  gets  a  cold  drink,  which  causes  a  rigor ;  was  admitted  into  hospital 
yesterday.     Previous  to  this  had  taken  no  medicine. 

Present  symptoms :  violent  pain  or  rather  fulness  of  head ;  throbbing 
of  temporal  arteries;  pulse  110  ;  thorax  free  from  pain;  no  cough; 
epigastrium  and  abdomen  very  tense ;  no  tenderness  on  pressure ;  skin 
hot,  dry,  and  tinged  yellow ;  tongue,  white  and  dry ;  somewhat  moist* 
at  edges;  got  some  purgative  medicine,  which  procured  two  stools, 
fetid  and  of  a  dark  colour ;  urine  natural.  Apjplicentur  Hirudines  xx. 
temporibus.  ?>  Liquoris  Acetatis  Amfnonice,  Aqua  Fontanel,  singulorum, 
§iij. ;  Tartari  Emetici,  granum ;  Si/rujpi,  §i.  Misce.  Sumat  5ss.  omni 
hord.  Haheat  Enema  EmoUiens  vesper e, — January  16.  Leeches  were 
applied  at  6  p.  m.  ;  many  still  bleeding ;  eyes  and  skin  less  yeUow ; 
headache  less;  pulse  70,  regular;  a  shght  tendency  to  diaphoresis. 
Mepetantur  Medicamenta  ut  heri. — January  17th.  Not  much  head- 
ache ;  heat  and  pulse  natural ;  much  debility ;  tongue  clean  and  moist ; 
countenance  improved  ;  no  appetite  ;  bowels  free.  Convalescent. — 
January  26th.  Left  hospital  the  day  before  yesterday ;  and  that  even- 
ing experienced  rigor  and  headache.  Tongue  white  and  furred ;  pulse 
100  ;  skin  not  very  hot ;  abdomen  soft;  bowels  free ;  great  thirst ;  no 
headache  at  present.  Haheat  Haiistus  Efervescentes  cum  Carbonate 
ammonice. — January  27.  Respirations  36;  pulse  120;  abdomen  soft 
and  natural ;  a  good  deal  of  headache ;  tliirst ;  heat  of  skin*  flusliing 
of  face ;  tongue  as  yesterday.  Applicentur  Eirudines  xx.  temporibus, — 
January  28th.  Head  somewhat  relieved  ;  bled  all  night  from  leech- 
bites ;  much  tenderness  of  epigastrium;  pulse  125;  great  thirst;  no 
vomiting ;  some  yellowness  of  skin,  but  not  of  eyes.  ^  Pilulce  Hy- 
drargyrij  gr.  ix.  Extracti  Hyoscyami,  gr.  vi.  Misce.  Eiant  Pilulce  tres  ; 
Sumat  unam  quartis  horis. — January  29th.  Fever  diminished;  was 
extremely  weak  last  night,  and  had  great  distention  of  belly,  with 
swelling  and  tenderness ;  this  attributed  to  taking  too  large  quantities 
of  drink ;  was  reheved  by  a  large  oil  injection  three  times  repeated. 


YELLOW   FEVER.  203 

Very  little  yellowness  to-day.  Habeat  Haustus  HJffervescentes  cum  Car- 
bonate Ammoni(2, — January  81st.  Skin  hot;  pulse  110,  rather  weak  ; 
aU  the  symptoms  exacerbated  since  yesterday ;  much  thirst ;  tremor ; 
no  cough  nor  tenderness  of  belly ;  no  headache  nor  raving ;  but  little 
sleep ;  respirations  40 ;  bowels  free ;  much  nausea,,  but  no  vomiting. 
Habeat  Haustttm  Oleosum.  Rejoetantur  Haustus  Effervescentes  cum  Car- 
bonate Ammonim, — February  1st.  Pace  flushed :  no  headache ;  a  good 
deal  of  epistaxis  last  night;  dry  burning  heat  of  skin;  tongue  very 
red  at  tip  and  edges ;  parched  in  centre ;  vomited  last  night ;  much 
thirst;  no  tenderness  of  epigastrium;  respirations  36 ;  pulse  112;  no 
cough ;  complains  at  times  of  sense  of  distention  of  stomach.  Habeat 
Misturce  canipJior6s  cum  magnesia ,  §i.  ter  in  die, — February  2d.  No 
fever;   pulse  72.     Convalesced  slowly,  and  was  dismissed  cured. 

Here  the  crisis  of  the  relapse  was  better  marked  than  that  of  the 
first  attack,  and  occurred  on  the  9th  day  of  the  relapse.  One  of  the 
most  prominent  features  of  this  fever  was  the  distended  state  of  the 
epigastric  region,  in  the  first  attack  unattended  with  tenderness,  but  in 
relapse  accompanied  by  much  epigastric  tenderness.  It  is  probable 
therefore  that  the  distended  state  of  the  epigastric  region  proceeded  in 
both  instances  from  the  same  cause,  namely  inflammation  of  the  mu- 
cous membrane  of  the  stomach.  We  have  already  seen  that  this  in- 
flammation may,  and  generally  does  produce  very  great  tenderness ; 
this  case,  however,  seems  to  prove  that  inflammation  of  the  mucous 
membrane  of  the  stomach  may  occasionally  exist  without  producing 
tenderness.  We  have  found  both  the  extract  and  tincture  of  hyoscya- 
mus  extremely  useful  in  abating  irritability  and  procuring  sleep  in  the 
advanced  stages  of  fever.  In  the  fevers  attended  with  jaundice  we  were 
induced  to  combine  it  with  mercurials,  from  observing  the  frequent  oc- 
currence of  intus-susception  in  the  fatal  cases — still  bearing  in  mind, 
that  means  calculated  to  abate  the  inflammation  of  the  stomach  and 
intestines,  by  lessening  the  cause,  would  strike  at  the  root  of  the  spasm, 
and  thus  prove  the  best  antispasmodics.  This  plan  has  been  successful 
in  several  instances,  but  in  the  majority  of  the  yellow  cases,  we  regret 
to  say,  that  the  progress  of  the  disease  was  so  sudden,  mostly  terminat- 
ing in  24  hours  after  the  appearance  of  the  jaundice,  that  all  our  efibrts 
proved  ineffectual.  In  the  second  report  we  made  will  be  found  the 
history  of  the  dissection  of  several  of  those  cases  which  occurred 
after  February.  It  is  not  to  be  supposed  that  the  report  affords  spe- 
cimens of  all  the  varieties  of  fever  treated  during  the  time  it  embraces 
— we  have  omitted  to  detail  any  but  those  calculated  to  convey 
an  accurate  idea  of  the  general  character  of  the  epidemic  and  its 
peculiarities,  omitting   any   account   of  the  more   ordinary   forms    of 


294  CLINICAL  MEDICINE. 

maculated  and  typlms  fever,  which  were  not  unfrequently  observed.  It 
concludes  with  some  remarks  on  that  form  of  fever  which  was  accom- 
panied by  jaundice. 

Cases  of  probably  a  similar  natui-e  have  been  observed  by  Dr. 
Cheyne  and  others  in  former  epidemics,  but  in  no  other  epidemic  were 
they  so  frequent  or  so  fatal  in  this  city.  Those  who  are  familiar  with 
the  symptoms  and  morbid  appearances  observed  in  the  yellow  fever  of 
America,  the  West  Indies  and  of  Spain,  will  at  once  perceive  many 
striking  points  of  resemblance  between  yellow  fever,  properly  so  called, 
and  that  variety  of  fever  we  have  described.  In  both  the  yellow  colour 
depends  upon  the  presence  of  bile,  and  in  both  the  absorption  of  bile, 
into  the  system,  seems  independent  of  hepatic  inflammation  or  obstruc- 
tion in  the  bihary  ducts.  We  are  aware  that  Tommasini,  in  his  excel- 
lent work  upon  the  fever  which  occurred  at  Leghorn  in  1 804,"^  proves 
that  the  liver  is  inflamed  not  unfrequently  in  yellow  fever,  and  he  sup- 
poses that  it  is  inflamed  in  all  cases,  arguing  that  where  no  very  visible 
or  external  marks  of  hepatic  inflammation  have  been  observed,  that  still 
inflammation  may  have  existed  in  the  internal  parts  of  the  liver^  attack- 
ing cliiefly  its  vascular  system  and  the  pori  biHarii  {Page  315.).  As, 
however,  no  such  inflammation  to  our  knowledge,  has  been  detected  in 
those  cases  of  yellow  fever  which  present  an  apparently  healthy  state 
of  the  liver,  and  as  the  most  accurate  descriptions  of  the  morbid  ana- 
tomy of  yellow  fever  with  which  we  are  acquainted,t  report  a  healthy 
state  of  the  liver  in  the  majority  of  cases,  we  must,  for  the  present  at 
least,  consider  the  jaundice  of  yellow  fever  as  independent  of  hepatitis. 

An  inflamed  state  of  the  mucous  membrane  of  the  stomach,  often 
amounting  to  its  absolute  disorganization,  is  the  most  constant  and  the 
most  essential  morbid  appearance  in  yellow  fever  : — a  similar  state  of 
the  duodenum  is  likewise  frequent;  now  in  both  these  respects  our 
cases  agree  with  yellow  fever,  except  indeed  that  in  the  latter  the  disor- 
ganization of  the  mucous  membrane  is  greater ;  still  however  this  is 
only  a  difi'erence  in  degree  ;  and  in  one  of  our  cases  we  have  seen  that 
the  disorganization  of  the  mucous  membrane  was  fuUy  equal  to  that 
described  in  yellow  fever  attended  with  the  black  vomit ;  and  in  that 
case  the  stomach  contained  matter  very  similar  to,  if  not  absolutely 
identical  with,  the  black  vomit.  We  should  recoUect  also,  in  compar- 
ing these  two  forms  of  disease  together,  that  in  many  instances  of  yellow 
fever  there  is  no  black  vomit,  and  the  inflammation  has  in  such  persons 

*  Sulla  Febbre  di  Livorno,  e  suUa  Febbre  Gialla,  &c. 

•f  See  Laurence's  very  accurate  Dissections  of  subjects  Dead  of  the  Yellow  Fever,  made 
at  New  Orleans  during  the  years  1817-18-19.- Philadelphia  Journal,  Vol.  i.  New 
Series, 


YELLOW   FEVER.  295 

been  found  to  have  attained  a  degree  not  greater  than  was  observed  in 
our  cases.  The  tenderness  of  the  epigastrium,  so  prominent  a  feature 
in  yellow  fever,  occurred  in  all  our  patients ;  and  if  space  permitted, 
I  could  point  out  many  other  circumstance  of  similarity  between  these 
two  forms  of  fever.  It  may  appear  to  many  ridiculous  to  maintain  a 
similarity  between  these  cases  and  yellow  fever,  a  disease  of  warmer 
climates,  and  which  commits  such  fearful  ravages  wherever  it  appears. 
I  need,  however,  only  refer  to  the  works  of  Tommasini,  Bancroft, 
Dr.  James  Johnson,  Bartlett,  and  Clymer,  which  contain  ample  proofs 
that  even  in  the  warmest  latitudes  epidemics  of  yellow  fever  are 
always  mixed  with  fevers  of  a  bilious  character,  but  of  a  milder  type ; 
a  circumstance  which  renders  it  highly  probable,  that  were  such  an  epi- 
demic influence  at  any  time,  from  a  particular  combination  of  circum- 
stances, to  spread  to  temperate  latitudes  the  reverse  would  happen,  and 
this  influence  would  then  produce  an  epidemic  of  bilious  or  gastric 
character,  with  comparatively  few  cases  approaching  in  violence  to  yel- 
low fever. 

Tommasini  and  the  best  modern  pathologists  consider  it  as  now 
placed  beyond  all  doubt,  that  yellow  fever  cannot  be  considered  as  a 
specific  disease,  but  merely  as  the  maximum  of  bilious  or  gastric  fever. 
By  some  it  has  been  considered  as  a  variety  of  remittent,  but  nearly 
all  the  late  waiters  agree  in  regarding  it  as  a  continued  fever."^  In  pro- 
portion to  the  warmth  of  the  climate  these  fevers  increase  in  intensity. 
Thus,  in  Cadiz  and  Gibraltar  we  need  not  be  surprised  at  the 
occasional  appearance  of  the  yellow  fever,  approaching  in  violence  to 
that  of  the  southern  parts  of  North  America  and  the  West  Indies. 
At  Leghorn  the  resemblance,  although  still  striking,  was  not  so  perfect : 
and  again,  in  the  bilious  epidemics  of  Trance,  Holland,  and  Germany, 
the  diff'erence,  as  to  intensity,  is  still  greater,  (Tommasini,  81,  82,  83,) 
but  still  the  disease,  in  its  essential  characters,  remains  the  same  in  all, 
and  the  same  symptoms,  and  the  same  morbid  lesions  are  found ; — they 
diff'er  only  in  degree.  Hitherto  we  have  not  made  any  remarks  on  the  fre- 
quent occurrence  of  spasmodic  action  of  the  intestines,  as  proved  by  the 
intus-susceptions  so  constantly  observed  in  our  cases ;  a  circumstance^ 
we  believe^  peculiar  to  those  cases,  for  we  have  not  met  with  any  account 
of  a  similar  occurrence  in  other  epidemics.  How  far  such  spasms,  either 
by  directly  causing  a  temporary  constriction  of  the  ductus  communis 
choledochus  where  it  enters  the  intestine,  or  by  extending  to  that  duct 
itself,  may  have  contributed  to  obstruct  the  passage  of  the  bile  and 
produce  the  jaundice,  is  a  question  worthy  of  consideration. 

•  Clymer  on  Fevers.     Philadelphia,  1846,  p.  349. 


^96  CLINICAL    MEDICINE. 

On  looking  over  my  papers  I  found  the  following  notes  of  a  clinical 
lecture  delivered  at  the  Meath  Hospital  in  the  year  1827.  As  they 
have  especial  reference  to  the  subject  under  consideration,  I  shall  make 
no  apology  for  introducing  them  in  this  place,  merely  premising  that 
they  are  printed  as  they  stand  in  the  manuscript,  and  must  be  regarded  _ 
as  the  heads  of  a  lecture,  and  not  as  conveying  all  that  I  may  have  said 
on  the  occasion  : — 

In  fact  there  is  not  so  much  difference  between  the  diseases  of  Ire- 
land and  warmer  countries,  as  has  been  imagined.  They  differ,  it  is 
true,  as  to  their  degrees,  but  not  as  to  their  pathology. 

It  was  an  opinion  long  ago  advanced  by  the  late  Dr.  Whitley  Stokes,  that 
almost  all  fevers  pass  into  each  other — thus  intermittent  may  become 
continued,  and  typhus  fever,  perhaps,  but  an  inferior  grade  of  plague. 
Be  this  as  it  may,  each  particular  epidemic  has  a  grade  peculiar  to  it- 
self. The  present  fever  in  Dublin,  the  most  worthy  of  notice  we  have 
had  here — strongly  proves  that  our  diseases  differ  only  in  degree  from 
those  of  warmer  latitudes.  We  have  had  numerous  cases  which  in 
their  symptoms,  and  their  morbid  anatomy,  agree  essentially  with  the 
yellow  fever.  This  is  an  opinion  I  have  never  before  expressed,  as  I 
was  unwilling  to  do  so  until  after  careful  examination  and  study.  Pass- 
ing events  always  make  a  deep  impression  when  the  attention  improperly 
directed  towards  them.  I  stand  here  to  improve  you,  if  I  can,  in  the 
pathology  and  practice  of  physic,  and  scruple  not  to  deviate  a  little 
from  my  course,  if  that  deviation  be  calculated  to  awaken  your  attention 
to  an  important  subject. 

1st.  In  both,  patients  become  yellow  from  absorption  of  bile  into 
the  system  ;  but  observe,  in  epidemics  of  yellow  fever  it  never  happens 
that  all,  or  even  most  of  the  cases  turn  yellow. 
2nd.  These  yellow  cases  are  here  equally  fatal. 
3rd.  Tenderness  of  epigastrium,  and  vomiting  in  both. 
4th.  The  strongest  die. 

5th.  Jaundice  does  not  depend  on  hepatitis  in  either. 
6th.  Nor  on  2ii\y  permanent  obstruction  in  gall  ducts. 
7th.  In  both,  the  essential  character  of  the  disease  is  a  violent  in- 
flammation of  the  mucous  membrane  of  stomach  and  duodenum ;  which 
becomes  dark  purple,  soft,  and  semifluid. 

8th.  Black  vomit  in  true  yellow  fever  consists  of  a  sanguineous  fluid ; 
the  mixed  vitiated  secretion  of  the  stomach  and  the  blood  forming  the 
coffee-grounds  appearance.  This  black  vomit  we  found  in  one  of  our 
patient's  stomach. 

9th.  Enlarged  state  of  the  spleen. 

What  is  the  cause  of  yellowness  in  yellow   fever  ?     Absorption  of 


YELLOW    FEVER.  297 

bile.     But  what  causes  bile  to  be  impeded — there  is  no  obstruction  in 
the  liver  itself — as  in  hepatitis,  or  in  the  ducts — as  in  gall-stoneSj  &c.  ? 

It  has  been  ascribed  to  vomiting ,  but  this  is  not  the  true  cause. 

1st.  It   has   appeared   in   yellow  fever  when  there  was  no  vomiting. 

2nd.  We  do  not  find  that  constant  vomiting,  as  in  sea-sickness, 
however  long  it  lasts,  produces  jaundice.  On  the  contrary,  vomiting 
is  often  used  as  a  cure  for  jaundice,  as  it  produces  a  greater  flow  of 
bile  from  ducts. 

The  opinion  of  Broussais  seems  most  correct,  that  the  yellow  colour 
depends  solely  on  the  violent  irritation  of  the  duodenum,  which  is  pro- 
pagated to  the  secreting  organ,  the  liver. 

This  is  nearest  the  truth,  but  still  does  not  seem  quite  satisfactory. 
If  the  irritation  or  inflammation  of  the  duodenum  was  propagated  to 
the  liver,  we  must  expect  to  find  that  organ  inflamed.  However  no 
such  thing  occurs  i^i  cither  case. 

ISTow  our  dissections  have,  I  think,  thrown  a  new  light  on  the  sub- 
ject, and  shown  the  true  nature  of  the  obstruction  to  the  flow  of  the 
bile  which  exists  in  this  complaint.  In  almost  all  the  cases  of  fever 
with  jaundice  which  have  proved  fatal,  we  have  found  one  or  more  intus- 
susceptions of  the  small  intestines,  without  any  inflammation  of  the  in- 
vaginated  part  (serous  membrane.)  Noav  let  us  consider  what  aid  we 
receive  from  the  finding  of  these  intus-susceptions,  towards  explaining 
the  origin  of  the  jaundice.  But,  first,  what  is  the  origin  of  spasm  ? 
Inflammation  of  the  mucous  membrane  of  duodenum,  and  small  intes- 
tines, and  stomach.  In  dysentery  we  find  evident  spasm  of  large  in- 
testines from  inflammation,  tenesmus,  &c.  Well,  then,  having  ren- 
dered it  probable  that  spasm  exists,  depending  on  inflammation,  how 
does  this  bear  on  jaundice  ?  We  have  all  heard  of  spasm  of  the  gall 
ducts  causing  jaundice,  and  best  treated  by  opium,  baths,  &c. 

We  must  suppose  spasm  in  the  duodenum  capable  of  being  propa- 
gated to  the  ducts,  or  of  directly  shutting  the  duct. 

This  spasm  constantly  occurring,  produces,  every  time  it  takes  place 
a  constriction  of  the  duct,  while  the  quantity  of  bile  is  not  diminished, 
the  consequence  of  which  is  jaundice. 

Having  thus  proved  a  remarkable  coincidence  between  these  diseases, 
if  not  their  absolute  identity,  let  us  see  how  their  treatment  agrees. 
We  have  found  by  experience  that  the  only  treatment  which  will  serve 
patients  in  these  cases,  is  that  which  has  been  adopted  in  yellow  fever 
by  the  most  enlightened  and  experienced  physicians — depletion  by  lan- 
cet and  leeches,  and  large  doses  of  calomel,  blue  pill,  hyoscyamus,  &c. 

At  the  time  these  remarks  were  penned,  I,  in  common  with 
others,  believed  that  all  efferent  ducts  possessed  a  vital  contractility, 


t9^ 


CLINICAL   MEDICINE. 


because  we  had  observed  many  phenomena  which  could  only  be  ex- 
plained on  this  supposition.  Since  then,  physiologists  have  applied 
themselves  to  the  solution  of  this  question,  and  it  is  now  generally  ad- 
mitted that  these  ducts  do  possess  the  power  of  contraction,  for  which 
they  are  indebted  to  a  muscular  coat.  I  shall  here  quote  from  the 
highest  authority  we  possess  : 

"The  efferent  dticts  of  glands  are  hned  by  a  mucous  membrane, 
which  has  on  its  exterior  an  extremely  thin  layer  of  muscular  substance. 
The  existence  of  muscular  fibres  cannot,  it  is  true,  be  demonstrated  ana- 
tomically, but  physiological  observations  place  it  beyond  dispute.  The 
efferent  ducts  of  most  glands  have  the  power  of  contracting  when  irri- 
tated. The  contractile  power  of  the  ductus  choledochus  in  birds  was 
known  to  Rudolphi.  By  irritating  mechanically,  or  by  galvanism, 
the  ductus  choledochus  of  a  bird  just  dead,  I  have  frequently  produced 
a  very  strong  contraction  of  it,  which  contiued  some  minutes,  after 
which  the  duct  resumed  its  previous  state.  I  have  often  excited  strong 
local  contraction  of  the  ureters  hkewise,  both  in  birds  and  in  rabbits, 
by  the  application  of  a  powerful  galvanic  stimulus.  Tiedemann  also 
has  seen  motions  in  the  vas  deferens  of  a  horse,  ensue  on  the  application 
of  a  stimulus.  It  appears,  indeed,  that  periodic  vermicular  motions  are 
performed  by  the  efferent  ducts,  at  least  by  the  ductus  choledochus  in 
birds;  for  once  in  a  bird  just  killed,  I  observed  contractions  of  the  duct 
to  occur  regularly  in  pauses  of  several  minutes  ;  the  tube  dilating  again 
in  the  intervals.  It  was  here  remarkable,  that  the  contractions  took 
place  in  an  ascending  direction,  namely,  from  the  intestine  towards  the 
Hver ;  which  seems  to  throw  some  light  on  the  mode  in  which  the  bile 
at  certain  times,  instead  of  being  expelled  into  the  intestines,  is  retained 
and  driven  into  the  diverticulum  of  the  duct,  namely,  the  gall-bladder,  the 
complete  closure  of  the  mouth  of  the  duct  contributing  perhaps  to  this 
effect. 

"  The  discharge  of  the  bile  from  the  gaE-bladder  during  digestion 
results  probably  from  the  mere  pressure  of  the  surrounding  parts,  and 
the  action  of  the  abdominal  muscles,  while  the  mouth  of  the  duct  is 
open :  for  I  doubt  if  the  bladder  is  contractile :  I  could  produce  no 
contraction  of  it  in  mammalia  and  birds,  even  with  the  most  powerful 
stimulus  of  a  galvanic  battery ;  and  in  this  respect  it  differs  from  the 
other  diverticula  of  efferent  ducts,  namely  the  urinary  bladder,  and  the 
vesiculse  seminales,  wliich  it  resembles  in  all  its  characters. 

"  Dr.  G.  H.  Meyer  however  states,  that  by  means  of  a  galvanic 
battery  of  fifty  pairs  of  plates,  he  has  caused  the  gall-bladder  of  an  ox 
to  contract  so  as  to  diminish  its  capacity  one-fourth. 

"  How  far  the  contractility  of  the  ducts  may  contribute  to  the  fre- 


YELLOW    FEVER.  299 

quently  sudden  expulsion  of  the  saliva  and  tears,  is  a  question  wliich  I 
mention  merely,  as  requiring  further  investigation.  I  may,  in  con- 
clusion, remark,  that  since  the  contractility  of  the  ducts  of  glands  is 
proved  experimentally,  the  spasm  of  these  parts,  spohen  of  hy  physicians, 
ceases  to  he  a  mere  hypothesis!''^ 

It  may  be  well  now  briefly  to  consider  how  far  the  Dublin  fever  of 
1826 — 7,  agreed  with  that  since  observed  at  Gibraltar,  by  Louis. 

The  prominent  symptoms  in  the  yellow  fever  of  Gibraltar  were,  flush- 
ing of  the  face,  headache,  suffusion  and  pain  in  the  eyes,  pains  in  the 
limbs,  thirst,  loss  of  appetite ;  it  was  rare  that  the  patient  complained 
of  any  pain  in  the  epigastrium  at  first,  hut  this  generally  came  on  1^  or 
16  hours  from  the  commencement  of  the  disease,  and  was  then  inconsi? 
derahle,  and  very  few  patients  complained  of  severe  or  acute  pain.  The 
abdomen  preserved  its  form,  was  supple  and  indolent,  except  in  the 
epigastric  region.  The  yellow  appearance  of  the  skin  did  not  come  on 
till  late  in  the  disease,  and  was  seldom  very  intense,  and  it  was  about 
the  same  period  that  the  vomiting  and  dejections  assumed  their  peculiar 
character ;  the  dejections  were  black  or  blueish,  and  the  matter  vomited, 
from  being  of  a  yellow  colour,  became  black  or  brown.  You  will 
at  once  perceive  that  the  symptoms  which  attended  the  cases  of  yellow 
fever  we  witnessed  in  1826,  indicated  a  more  intense  disease  of  the 
abdominal  viscera — in  all  there  was  tenderness  over  the  epigastrium, 
which  in  some  was  excessive — ^black  vomiting  did  not  occur  in  all,  but 
even  in  the  yellow  fever  of  tropical  countries  it  is  not  constant,  but  the 
symptom  which  presented  the  greatest  difference  in  the  two  epidemics 
was  the  yellowness  of  the  skin,  wliich  in  the  fever  of  Gibraltar  came  on 
towards  the  latter  period  of  the  disease,  and  was  seldom  very  intense,  but 
in  our  fever  it  came  on  suddenly,  immediately  after  the  tenderness  of 
the  epigastrium  was  complained  of,  and  was  in  all  very  intense.  This 
shows  that  whatever  lesion  produced  the  yellowness  in  the  Gibraltar 
fever,  was  either  different  in  kind,  or  in  degree,  from  that  which  caused 
it  in  ours,  and  I  think  we  cannot  doubt  but  that  it  was  here  produced 
by  spasm  of  the  ducts  leading  from  the  liver  and  gall-bladder. 

It  is  well  known  to  pathologists  since  the  time  of  Broussais,  that 
jaundice  is  as  frequently  produced  by  duodenitis  as  hepatitis  if  not  more 
so — but  I  do  not  think  that  the  explanation  he  gives  is  applicable  to  our 
cases.  He  concludes  that  when  the  mucous  surface  of  the  duodenum 
is  thrown  into  a  state  of  excitement,  we  may  have  a  consequent  affection 
of  the  liver,  for  the  duodenum  bears  the  same  relation  to  the  liver  as 
the  mouth  does  to  the  parotid  gland,  and  we  know  that  an  irritation  of 

•  Mullet's  Physiology  ;  translated  by  Baly,  2nd  edition,  p.  620. 


800  CLINICAL   MEDICINE. 

the  orifice  of  the  ducts  leading  from  this  and  other  salivary  glands  is 
immediately  followed  by  an  increased  flow  of  their  secretions.  But  our 
dissections  have  shown  that  the  small  intestines  were  affected  not  only 
by  inflammation^  but  were  acted  upon  by  violent  spasms,  producing  in- 
vaginations of  different  portions  of  the  canal ;  and  there  can  be  no 
doubt  that  the  ducts  (possessing  such  considerable  vital  contractility) 
participated  in  these  spasms,  and  thus  prevented  the  flow  of  bile  into 
the  duodenum,  as  effectually  as  if  they  were  tied  by  a  ligature,  or  their 
canals  obstructed  by  calculi,  and  this  explanation  obtained  great  support 
from  the  fact,  that  the  jaundice  came  on  mddeyilyj  in  most  of  the  cases, 
and  was  alwai/s  jjreceded,  or  accomjoafiied,  hy  violent  and  convulsive  con- 
tractions of  the  abdominal  muscles  and  intestines. 

There  is  another  point  to  which  I  am  anxious  to  direct  attention. 

The  yellow  fever  I  have  now  described  occurred  in  the  course  of  an 
epidemic  of  continued  fever,  whose  type  was  a  severe  and  very  fatal  form 
of  gastro-duodenitis.  Does  not  this  circumstance  tend  to  confirm  the 
opinion  of  Tommasini  and  others,  that  yellow  fever  is  but  a  more  severe 
form  of  the  gastric  variety  of  typhus  ?  The  appearance  of  the  liver 
described  by  Louis  has  not  been  noticed  by  other  pathologists,  and  can- 
not be  considered  the  essential  anatomical  character  of  yellow  fever 
generally ;  for  we  read  that  Rush,  Lawrence,  Jackson,  and  Ashbel 
Smith,  the  learned  writers  on  the  yellow  fever  of  America,  seldom  found 
the  jaundice  connected  with  liver  disease,  but  that  in  all  cases  there  was 
inflammation  of  the  digestive  surface  :  and  in  the  late  epidemic  of  yellow 
fever,  which  prevailed  in  Martinique  from  1839  to  1841,  M.  Euiz 
states,  that  he  observed  the  yellow  appearance  of  the  liver,  described  by 
Louis,  only  in  two  instances,  and  that  this  organ,  like  the  rest  of  the 
solid  viscera,  was  very  often  gorged  with  blood. 

Dr.  Nott  says — "Of  eight  cases  dissected  during  the  epidemic  of 

1843,  in  Mobile,  the  livers  in  two  only  corresponded  with  the  description 
of  M.  Louis.  They  were  pale,  and  when  torn  resembled  very  closely 
gingerbread  or  new  leather ;  and  the  six  others  were  of  a  dark  blue  or 
dark  chocolate,  presenting  different  shades  of  colour,  and  instead  of  being 
dry  they  were  excessively  engorged  with  blood.  The  latter  cases  corres- 
pond with  the  description  given  by  Dr.  Hulse  of  the  cases  dissected  in 
the  Marine  Hospital  at  Pensacola  in  1841.     Of  the  eight  dissections  in 

1844,  the  livers  in  four  corresponded  with  the  description  of  Louis,  two 
were  of  a  dark  oHve,  and  two  were  perfectly  natural.  Taking  the  whole 
sixteen  cases  collectively,  six  were  some  shade  of  yellow,  dry  and  friable ; 
two  ohve ;  two  normal ;  and  six  darker  than  natural,  and  much  engorged.'' 
Dr.  Nott  also  thinks  that  Louis  has  fallen  into  another  error  in  sup- 

,   posing  this  liver  to  be  peculiar  to  yellow  fever,  for  he  has  repeatedly 


YELLOW   I'EVER.  801 

met  with  it  in  individuals  dying  of  other  diseases^  and  who  never  had  yellow 
fever. 

In  the  Martinique  epidemic,  the  principal  pathological  appearances 
were  the  following : — "  The  stomach  contained  matter  of  a  black  colour, 
generally  in  great  quantity,  and  the  mucous  membrane  was  coloured  by 
this  substance ;  but  when  ihe  contents  were  removed,  and  the  mucous 
membrane  washed,  he  found  that  it  presented  a  beautiful  rose-coloured 
hue,  extending  all  over  its  surface,  and  not  produced  by  distinct  vascular 
arborisations.  In  the  midst  of  this  redness,  he  observed  several  round 
and  distinct  spots,  produced  by  the  effusion  of  small  quantities  of  dark- 
coloured  blood,  having  all  the  appearance  of  spots  oi  purpura  JKEmorrha- 
glca.  The  mucous  membrane  was  neither  thickened  nor  softened,  but 
was  evidently  much  more  easily  detached  than  in  the  natural  condition. 
The  small  intestines  contained  a  greyish  white  matter,  particularly  the 
jejunum ;  the  mucous  membrane  presented  precisely  the  same  appearance 
as  the  stomach,  but  the  hemorrhagic  spots  were  more  numerous  and 
much  larger.  The  glands  of  Brunner  were  in  a  few  cases  enlarged  to 
the  size  of  millet  seeds — but  in  no  instance  were  the  glands  of  Peyer  in 
the  least  altered." 

During  the  prevalence  of  the  yellow  fever  in  1826-27,  a  captain  of  a 
West-Indian  vessel  was  admitted  into  hospital  with  the  disease.  He  had 
yellow  fever  in  Jamaica,  and  stated  positively  that  he  was,  when  under 
our  care,  affected  in  precisely  the  same  manner  as  he  had  been  in  Jamaica; 
and  he  also  remarked  that  the  other  patients  seemed  to  labour  under 
exactly  the  same  kind  of  fever  as  he  had  then  witnessed. 

The  correctness  of  the  views  here  propounded  as  to  the  identity  of 
the  cases  of  yellow  fever  occurring  in  the  Irish  epidemic  of  1826-27, 
with  the  yellow  fever  of  warmer  chmates  has  been  singularly  and  remark- 
ably proved  by  the  Scotch  epidemic  of  1843-44,  in  which  cases  of  yellow 
fever  were  very  frequent.  Dr.  Arrott,  Physician  to  the  Dundee  Infir- 
mary, says,  "  The  similarity  of  the  s}Tnptoms  during  life,  and  of  the  mor- 
bid appearances  observed  after  death,  so  nearly  agree  with  the  description 
of  the  yeUow  fever  of  the  West  Indies,  and  with  the  minute  accounts  of 
the  Gibraltar  epidemic  of  ]  828,  given  by  Louis,  as  to  leave  little  doubt 
on  my  mind,  that  the  only  difference  between  these  diseases  and  the 
Dundee  epidemic,  if  difference  there  be,  is  a  difference  in  degree  and  not 
in  kind."  And  Dr.  Cormack,  in  his  Essay  on  this  fever,  remarks,  "  That 
hi  all  stages  of  this  disease,  it  is  the  affection  of  the  stomach  that  affords 
the  most  distinguishing  and  important  symptoms.  As  it  advances,  an 
unconquerable  irritability  of  this  organ  comes  on.  Whatever  is  swal- 
lowed, whether  solid  or  fluid,  of  whatever  quantity  or  quality,  is  imme- 


302  CLINICAL   MEDICINE. 

diately  rejected  by  'vomiting.  An  almost  incessant  retching  takes  place 
even  without  any  extraneous  irritation^  which  commonly  on  the  third  day 
ends  in  what  is  called  the  black  vomit,  the  most  hopeless  of  all  the  symp- 
toms attending  it/' 

In  June  1846,  during  the  very  hot  weather  which  then  prevailed,  I 
saw  two  fatal  cases  of  yeUow  fever.  The  first  was  a  very  atliletic  gentle- 
man, 24  years  of  age,  who  overheated  himself  by  violent  exercise,  after 
having  travelled  without  resting  during  the  night.  Being  exposed  to  a 
thorough  air  he  was  chilled,  and  having  spent  a  restless  night,  on  the 
following  day  was  attacked  with  intense  fever,  nausea,  vomiting,  thirst, 
pain  in  the  head,  &c. ;  he  became  yellow  on  the  third  day,  and  died  on 
the  fifth, — without  black  vomit. 

The  second  I  saw  with  Mr.  O'Eeilly  of  Sackville-street.  It  was  the 
case  of  a  captain  of  one  of  the  Liverpool  Mail  Packets,  who  got  a  chiU 
in  the  railway  carriage  coming  from  Kingstown,  when  in  a  perspiration, 
and  was  attacked  next  day  with  violent  fever — gastric  and  cerebral 
symptoms  predominated,  and  about  the  sixth  day  he  became  tympanitic, 
had  black  vomit,  and  died  on  the  eighth  day. 

I  also  saw  a  third  case  in  the  summer  of  1847,  in  a  young  girl, 
aged  about  14,  which  terminated  fatally ;  the  only  morbid  appearance  to 
be  observed  on  post-mortem  examination  which  could  have  any  connec- 
tion with  the  disease  was,  that  the  gaU-bladder  was  completely  empty  of 
bile. 


303 


LECTURE  XXII. 

SCARLATINA. EPIDEMIC   OF   1801-2-3-4. EPIDEMIC   OF    1834. 


It  is  my  intention  to-day  to  make  some  observations  on  the  scarlet 
fever  which  now  prevails  as  a  destructive  epidemic  in  Dublin,  and  many 
other  parts  of  Ireland.'^  The  history  of  such  epidemics  is  very  interest- 
ing, and  tends  to  shed  much  light,  not  only  upon  the  changes  which 
diseases  undergo,  but  upon  the  fluctuations  of  medical  opinions  and 
treatment. 

In  the  year  1801,  in  the  months  of  September,  October,  November, 
and  December,  scarlet  fever  committed  great  ravages  in  Dublin,  and  con- 
tinued its  destructive  progress  during  the  spring  of  1802.  It  ceased  in 
summer,  but  returned  at  intervals  during  the  years  1803-4,  when  the  dis- 
ease changed  its  character ;  and  although  scarlatina  epidemics  recurred 
very  frequently  during  the  next  twenty-seven  years,  yet  it  was  always  in  the 
simple  or  mild  form,  so  that  I  have  known  an  instance  where  not  a  sin- 
gle death  occurred  among  eighty  boys  attacked  in  a  public  institution. 
The  epidemic  of  1801-2-3-4,  on  the  contrary,  was  extremely  fatal,  some- 
times terminating  in  death,  so  early  as  the  second  day,  as  appears  by 
the  notes  of  Dr.  Percival,  kindly  communicated  to  me.  It  thinned 
many  famiUes  in  the  middle  and  upper  classes  of  society,  and  even  left 
not  a  few  parents  childless.  Its  character  seems  to  have  answered  to  the 
definition  of  the  scarlatina  maligna  of  authors,  for  a  description  of  which 
I  beg  leave  to  refer  you  to  the  Cyclopaedia  of  Practical  Medicine,  where 
you  wiU  find  an  article  on  the  subject  by  Dr.  Tweedie.  In  making  this 
reference,  however,  I  do  not  wish  to  be  understood  as  expressing  my 
unqualified  approbation  of  the  article  in  question,  for  I  must  in  candour 
confess  that  it  falls  far  short  of  what  we  might  have  expected  from  a 
physician  of  Dr.  Tweedie^s  learning  and  experience. 

The  long  continuance  of  the  period  during  which  the  character  of 

*  This  lecture  was  delivered  during  the  session  of  1834-5. 


SO'i  CLINICAL    MEDICINE. 

scarlet  fever  was  either  so  mild  as  to  require  little  care,  or  so  purely  in- 
flammatory as  to  yield  readily  to  the  judicious  employment  of  an  anti- 
phlogistic treatment,  led  many  to  believe  that  the  fatality  of  the  former 
epidemic  was  chiefly,  if  not  altogether,  owing  to  the  erroneous  method 
of  cure  then  resorted  to  by  the  physicians  of  Dublin,  who  counted  among 
their  numbers  not  a  few  disciples  of  the  Brunonian  school ;  indeed,  this 
opinion  was  so  prevalent,  that  all  those  whose  medical  education  com- 
menced at  a  much  later  period,  were  taught  to  believe  that  the  diminished 
mortality  of  scarlet  fever  was  entirely  attributable  to  the  cooling  regimen^ 
and  to  the  timely  use  of  the  lancet  and  aperients,  remedies  interdicted 
by  our  predecessors.  This  was  taught  in  the  schools,  and  scarlet  fever 
was  every  day  quoted  as  exhibiting  one  of  the  most  triumphant  examples 
of  the  efficiency  of  the  new  doctrines.  This  I  myself  learned — this  I 
taught ;  how  erroneously  will  appear  from  the  sequel.  It  was  argued, 
that  had  the  cases  which  proved  fatal  in  1801-2  been  treated  by  copious 
depletion  in  their  very  commencement,  the  fatal  debility  would  never 
have  set  in,  for  we  all  regarded  this  debility  as  a  mere  consequence  of 
previous  excessive  reaction.  The  experience  derived  from  the  present 
epidemic  has  completely  refuted  this  reasoning,  and  has  proved  that,  in 
spite  of  our  boasted  improvements,  we  have  not  been  more  successful  in 
1834-5  than  were  our  predecessors  in  1801-2. 

Before  I  detail  more  particularly  the  symptoms  that  accompany  the 
present  epidemic,  I  wish  to  enter  a  little  at  large  into  the  subject  of  the 
changes  and  variations  w^hich  the  same  disease  is  observed  to  undergo 
at  different  periods  of  time.  This  is  a  topic  which  occupied  some  of 
the  master  minds  of  antiquity,  and  upon  which  the  greatest  of  modern 
physicians,  the  illustrious  Sydenham,  bestowed  considerable  labour.  It 
has  been  too  much  neglected  of  late,  and  consequently  I  consider  it  my 
duty  to  call  your  attention  to  it,  and  I  cannot  do  this  better  or  more 
forcibly  than  by  communicating  to  you  a  literal  translation  which  I 
have  made  from  the  German  of  my  friend  Dr.  Autenrieth's  observations 
on  this  subject.  The  task  of  translation  is  always  not  only  difficult  but 
irksome ;  but  if  as  in  the  present  instance,  I  can  by  this  means  convey 
to  you  valuable  information  not  before  presented  to  my  class,  or  to  the 
public  in  England,  I  never  decline  the  labour.  What  I  am  now  about 
to  read  is,  indeed  most  important,  and  well  deserves  the  deep  attention 
of  every  practicd  physician. 

"  The  third  cause,  connected  with  time  and  capable  of  modifying  dis- 
eases, is  of  infinite  importance,  both  in  a  theoretical  and  practical  point 
of  view,  but  has  seldom  attracted  much  attention.  Its  existence  is  attested 
by  its  effects  alone,  for  its  nature  remains  unknown.  I  allude  to  the 
constitutio  morlorum  stationaria,  first  noticed  by  Sydenham,  but,  since 


SCARLATINA.  305 

his  time,  nearly  forgotten_,  or  else  confounded  witli  the  permanent  influ- 
ence of  the  seasons,  or  the  accidental  atmospherical  changes  spoken  of 
above.  All  diseases,  contagious  and  non-contagious,  acute  and  chronic, 
(the  latter  however,  seldom,  except  when  attended  with  some  degree  of 
general  excitement,)  have  been  observed  to  preserve  a  certain  constitution 
or  general  character,  which  continues  for  a  number  of  years  in  succession, 
with  occasional  interruptions,  until  it  is  displaced  by  another  constitution 
of  a  different  character.  Thus,  during  one  period,  diseases  are  remark- 
able for  being  frequently  accompanied  by  a  sensation  of  extreme  w^ear- 
iness,  sudden  sinking  of  the  strength  and  vital  powers,  unpreceded  by 
any  evident  marks  of  excitement,  and  attended  by  a  disposition  to  pass 
into  true  typhus.  During  another  period,  the  tongue  is  in  general  loaded 
with  a  thick  white  or  yellowish  coat,  and  many  other  symptoms  of  de- 
rangement in  the  digestive  organs,  such  as  a  bitter  taste,  costiveness,  or 
diarrhoea,  are  constantly  observed. 

"  During  a  third  period,  diseases  are  characterised  by  a  remarkable 
degree  of  vascular  excitement,  an  evident  tendency  to  local  determina- 
tions, a  frequent  formation  of  morbid  productions ;  in  a  word,  by  all  the 
symptoms  of  inflammation, 

"  It  is  not  known  whether  the  transition  from  one  of  these  periodic 
constitutions  to  another  takes  place  suddenly  or  gradually ;  but  the  latter 
supposition  appears  more  probable,  except  when  the  transition  is  accom- 
panied by  unusually  great  atmospheric  changes.  The  erysipelatous  affec- 
tion, which,  both  in  England  and  Germany,  succeeded  the  gastric  and 
accompanied  the  first  appearance  of  the  inflammatory  period,  seems  to 
have  been  an  example  of  the  gradual  transition.  Accurate  observations 
are  still  wanting  to  determine  whether  this  periodic  constitution  is  con- 
fined to  certain  parts  of  the  world,  or  extends  over  the  whole,  and  whether 
its  different  species  follow  each  other  in  a  regular  order  of  succession. 
If  their  order  of  succession  should  at  any  time  be  determined,  it  will 
enable  the  physician  to  foretell  the  character  and  most  appropriate  treat- 
ment of  future  diseases.  The  above  questions  cannot  be  answered  with- 
out very  great  labour  spent  in  the  investigation  of  the  history  of  diseases 
in  all  ages  and  all  countries,  and  are  therefore  foreign  to  the  present 
work. 

"  The  general  indications  of  course  vary  with  the  nature  of  the  pre- 
vailing constitution ;  and,  consequently,  during  one  period  stimulating 
remedies,  during  another  alvine  evacuations,  and  during  a  third  venesec- 
tion and  the  antiphlogistic  plan,  wiU  constitute  the  most  effectual  treat- 
ment. 

"  This  very  circumstance  has  caused  much  confusion  in  medical  opi- 
nions, and  has  occasioned  the  reputation  and  the  downfall  of  many  an 

VOL.  I.  20 


306  CLINICAL   MEDICINE. 

infallible  system,  each  of  which  is  in  its  turn  consigned  to  obhvion,  and 
perhaps  again  revived  as  a  novelty  at  some  future  period.  The  English 
boast  much  of  the  astonishing  improvements  in  science,  and  deride  the 
ignorance  of  their  predecessors,  regardless  of  the  old  proverb — '  Every 
thing  has  its  day/  Whenever,  therefore,  the  periodic  constitution  un- 
dergoes an  alteration,  they  either  obstinately  uphold  their  usual  plan  of 
treatment  to  the  manifest  injury  of  their  patients,  or  else  blindly  embrace 
some  system,  to  them  new,  but  which  really  rests  upon  ancient  and  esta- 
blished principles.  In  general,  they  do  not  fail  to  make  use  of  so  much 
exaggeration  in  support  of  their  opinions,  and  thus  succeed  in  misleading 
so  many,  that  none  but  very  well  informed  physicians  can  distinguish  the 
fallacy  of  their  arguments. 

.  "  The  medical  history  of  Great  Britain  affords  many  striking  proofs  of 
the  truth  of  these  assertions,  and  is  replete  with  examples  of  the  singular 
obstinacy  with  which  the  English  cling  to  opinions  once  formed,  a  cir- 
cumstance which  has  materially  contributed  to  obstruct  their  attaining 
to  general  views  and  impartial  conclusions.  Even  to  this  day,  a  warm 
contest  is  carried  on  (less,  however,  in  books  than  in  the  debates  of 
learned  societies)  between  the  senior  and  the  junior  parts  of  the  profes- 
sion, the  former  still  inclining  to  Brunonianism,  while  the  latter  attribute 
nearly  all  diseases  to  inflammation.  Both,  indeed,  appeal  to  experience 
to  prove  the  justice  of  their  principles,  and  seem  entirely  to  forget  that 
while  the  propriety  of  their  practice,  as  applied  to  particular  cases,  re- 
mains unimpeached,  the  very  nature  of  the  diseases  themselves  may  have 
been  changed.  A  summary  review  of  the  character  assumed  by  diseases 
during  the  last  twenty  years,  both  in  England  and  other  countries,  will 
perhaps  afford  a  solution  of  this  question.  About  the  end  of  the  last 
and  during  the  tliree  or  four  first  years  of  the  present  century,  the  pro- 
portion of  nervous  fevers  to  other  diseases  was  as  one  to  eighteen  in 
Plymouth  (Woolcombe),  as  one  to  sixteen  in  London  (Willan),  as  one  to 
ten  in  Newcastle  (Clarke),  and  in  Liverpool,  one  to  five  (Curry).  Nor 
was  this  scourge  of  mankind  less  severely  felt  upon  the  continent,  where 
typhus,  and  diseases  closely  allied  to  it,  committed  extensive  devastations, 
particularly  during  the  epidemics  of  Erlangen,  Jena,  Kiel,  Eatisbon,  and 
Vienna.  Cadiz  and  Seville  were  at  the  same  period  depopulated  by  the 
yeUow  fever,  and  Europe  in  general  suffered  much  from  repeated  visita- 
tions of  influenza.  An  inclination  to  a  sudden  sinking  of  the  vital  power, 
unpreceded  by  violent  reaction,  and  unaccompanied  by  any  marked  symp- 
toms of  a  gastric  or  inflammatory  nature,  constituted  at  that  period  the 
characteristic  form  of  acute  diseases,  which  were  always  preceded  and 
attended  with  an  unaccountable  degree  of  debility.  Stimulating  and  tonic 
medicines  obtained,  therefore,  much  celebrity,  and  every  physician  who 


SCARLATINA.  307 

practised  during  that  period,  attests  the  injurious  or  even  fatal  effects 
which  were  produced  by  the  use  of  venesection,  and  other  depletory  re- 
medies. What  is  still  more  remarkable,  an  epidemic  typhoid  pneumonia 
prevailed  in  many  parts  of  Germany  during  the  years  1800-1-2,  in  which 
the  speedy  production  of  an  inflammatory  state,  by  means  of  bark  and 
ether,  was  the  only  method  which  afforded  a  chance  of  recovery.  These 
facts  must  impress  every  impartial  mind  with  the  conviction,  that  the 
constitution  of  diseases  has  undergone  much  alteration  since  that  period, 
and  explain  why  physicians  did  not  then  employ  copious  venesection,  but 
were  obliged  to  content  themselves  ordinarily  with  cold  affusions,  acids, 
and  mercury. 

"  The  reign  of  typhus  appears  to  have  ceased  with  the  influenza  of 

1804,  when  a  new  constitution  began,  at  first  more  remarkable  for  the 
disappearance  of  nervous  fevers  and  other  contagious  diseases,  than  for 
any  pecuHar  character  of  its  own.  Catarrhal  and  rheumatic  complaints, 
partly  attributable  to  the  weather,  prevailed  for  some  time,  and  fevers  of 
an  intermitting  type  became  more  frequent,  forming  an  evident  transi- 
tion from  the  purely  typhus  constitution  to  that  of  the  vascular  excite- 
ment of  the  following  years.  Some  remnant  of  the  typhus  constitution 
was  indeed  stiU  perceptible  in.  the  pectoral  complaints  which  prevailed 
in  London  during  the  winter  of  1804-5,  and  were  attended  with  re- 
markable debility,  requiring  the  greatest  prudence  in  the  use  of  the 
lancet.  Venesection  was  indeed  often  entirely  contraindicated,  and 
Bateman  states  it  sometimes  even  proved  fatal.  The  constitution,  how- 
ever, soon  developed  itself  more  decidedly,  became  more  universally  dif- 
fused, and  obhged  physicians  to  relinquish  their  former  plan  of  treat- 
ment and  adopt  other  measures.  Derangement  of  the  alimentary  canal 
became  its  prominent  feature  in  the  summer  and  autumn  of  1804,  and 
diarrhoea,  terminating  in  dysentery,  was  often  met  with. 

"This  constitution  suffered  indeed  a  check  from  the  cold  of  1805,  but 
it  increased  again  during  the  following  years,  and  afterwards  became 
still  more  prevalent,  manifesting  itself  by  headache,  a  bitter  taste  in  the 
mouth,  a  loaded  yellow  tongue,  irregularity  of  the  bowels,  nausea,  and 
anorexia.  The  utility  of  purgatives  now  became  so  obvious,  that  Hamil- 
ton's doctrines  soon  obtained  as  much  celebrity  as  had  been  before  en- 
joyed by  the  stimulating  system.  The  nervous  fever  at  Nottingham  in 
1807,  the  dysentery  at  London  in  1808,  the  scarlatina  at  Edinburgh  in 

1805,  and  the  measles  at  the  same  place  in  1808,  all  required  the  pur- 
gative plan  of  treatment,  and  calomel  became  the  favourite  cathartic. 
The  advantage  then  derived  from  the  use  of  purgative  medicines  is 
abundantly  testified  by  the  writers  of  that  period.  This  gastric  consti- 
tution appeared  also  on  the  continent,  but  its  progress  was  less  rapid 


308  CLINICAL  MEDICINE. 

there  than  in  England,  where  the  inhabitants  live  in  a  manner  calculated 
to  augment  or  even  to  produce  a  tendency  to  gastric  diseases.  There 
were  likewise  other  circumstances  which  impeded  the  formation  of  this 
constitution  on  the  continent.  Thus  in  Germany,  the  purely  nervous 
constituticgi  had  scarcely  yielded  to  catarrhal  and  rheumatic  affections, 
when  it  was  again  revived  in  that  unhappy  country  by  the  political  occur- 
rences of  1805-6-7.  Typhus,  seldom,  however,  assumed  the  character  of 
exquisite,  for  the  rheumatic  and  catarrlial  affections  with  which  it  was 
mixed  partook  somewhat  of  a  gastric  nature,  as  was  proved  by  the  great 
benefit  derived  from  the  exhibition  of  emetics  and  calomel.  This  appears 
in  accordance  with  the  fact  that  the  gastric  constitution  was  more  fully 
developed  wherever  tlie  ravages  of  war  had  not  extended,  although  it 
still  required  less  attention  in  the  treatment  than  the  rheumatic  symp- 
toms, then  likewise  prevalent.  Thus  the  agues  which  were  common  at 
Tubingen  about  the  end  of  1806,  commenced  in  general  with  pain  in 
the  belly,  vomiting,  and  irregularity  of  the  bowels ;  a  yellow  furred 
tongue,  headache,  and  tumours  of  the  parotids,  were  of  frequent  occur- 
rence, and  in  general  gastric  symptoms  were  by  no  means  rare.  These 
symptoms  gradually  gained  ground,  and  the  reputation  of  ipecacuanha 
and  cathartics  increased  in  the  same  proportion.  At  Ratisbon  the  con- 
stitution  was  remarkably  gastric  in  the  autumn  of  1809,  and  a  nervous 
fever  prevailed  at  Weimar  in  1809-10,  which  was  accompanied  by  bitter 
taste  in  the  mouth,  diarrhoea,  nausea,  and  vertigo.  Active  catharsis  was 
injurious  in  this  epidemic,  but  much  benefit  resulted  from  the  exhibition 
of  castor  oil.  The  advantage  derived  about  the  same  time  in  BerHn 
from  the  treatment  of  fevers  by  emetics  and  cooling  purgatives,  proved 
tlmt  they  were  there  also  complicated  with  gastric  derangement. 

"  The  gastric  constitution  had  scarcely  estabhshed  itself,  or  become 
pretty  generally  diffused,  when  a  new  character,  viz.  the  inflammatory, 
appeared  upon  the  stage,  and  has  ever  since  continued,  sometimes  com- 
bining itself  with  the  gastric  to  form  diseases  of  a  mixed  character, 
such  as  erysipelas,  and  sometimes,  when  favoured  by  the  seasons  or 
local  circumstances,  raising  itself  to  the  rank  of  the  chief  performer. 
With  its  appearance,  venesection,  which  had  previously  fallen  into  dis- 
repute, became  once  more  a  favourite  remedy,  and  in  the  course  of  a 
few  years  was  pushed  so  far,  particularly  in  Great  Britain,  that  San- 
grado^s  maxim,  '  C'est  une  erreur  de  penser  que  le  sang  soit  necessaire 
a  la  conservation  de  la  vie,  on  ne  pent  trop  saigner  un  malade,'  seems 
to  have  been  the  general  rule  of  practice.  The  same  inflammatory 
constitution  became  also  general  in  Germany,  but  there  it  neither 
attained  such  a  height,  nor  required  such  active  treatment  as  in  Great 
Britain,  where  many  circumstances  favoured  its  more  perfect  develop- 


SCARLATINA.  309 

ment ;  with  us  it  generally  yielded  to  the  use  of  acids,  cold  applications 
and  mercury,  but  in  England  it  called  for  copious  blood-letting.  Even 
in  1810,  diseases  had  become  more  inflammatory  at  Tubingen  than 
they  had  been  previously ;  but  the  change  was  stiU.  more  perceptible  in 
1813,  when  the  antiphlogistic  treatment  required  the  aid  of  small  vene- 
sections, and  nervous  fevers  were  accompanied  both  by  inflammation 
and  derangement  of  the  digestive  organs.  Erysipelatous  affections  were 
also  frequent,  and  in  many  cases  were  of  a  marked  inflammatory  cha- 
racter. Erysipelas  and  true  inflammatory  fever,  requiring  the  use  of 
the  lancet,  were  common  at  Eatisbon  in  1811.  Parrot  exliibited  acids, 
especially  the  acetous,  with  great  success  in  the  epidemic  nervous  fever 
which  raged  at  Dorpat  in  1812,  and  a  diarrhoea  of  a  bilious  inflamma- 
tory nature  prevailed  at  Konigsberg  during  the  same  year.  This  im- 
portant change  in  the  constitution  became  very  evident  in  the  nervous 
fever  at  Berlin  in  1813,  as  well  as  in  the  formidable  epidemic  described 
by  Hufeland,  which  ensued  after  the  w^ar,  and  raged  in  the  north  of 
Germany  during  that  and  the  preceding  year.  Although  but  a  few 
years  before,  the  strongest  stimulants  had  been  necessary  to  obviate  the 
paralysis  which  supervened  even  in  the  beginning  of  the  disease,  yet 
an  opposite  practice  was  now  required,  and  antiplilogistic  remedies 
were  alone  found  capable  of  preventing  the  vascular  excitement  from 
terminating  in  inflammation  of  either  the  head  or  chest.  In  short,  the 
inflammatory  constitution  has  been  prevalent  in  Germany  ever  since  the 
years  1810-11,  sometimes  in  its  pure  and  marked  form,  and  sometimes 
complicated  with  gastric  and  rheumatic  symptoms. 

"  This  constitution  became  general  at  the  very  same  period  in  Great 
Britain.  Dr.  Clutterbuck,  of  London,  had  indeed  ascribed  the  origin 
of  fever  to  inflammation  of  the  brain,  so  early  as  1807,  and  about  the 
same  time  Dr.  Steiglitz,  of  Hanover,  had  recommended  the  antiphlogistic 
treatment  of  scarlet  fever,  in  preference  to  the  stimulating  plan  then  in 
vogue.  But  as  the  inflammatory  was  then  still  subordinate  to  the 
rheumatic  and  gastric  constitutions,  their  opinions  did  not  gain  many 
converts.  But  the  inflammatory  constitution  had  increased  so  much  in 
the  autumn  of  1809,  and  the  winter  of  1810,  that  even  Bateman  was 
obliged  to  prescribe  venesection  in  fevers— a  practice  quite  at  variance 
with  his  former  views.  Erysipelatous  inflammation  became  common  in 
London,  Aberdeen,  and  Leeds,  and  numerous  cases  of  puerperal  fever 
occurred  in  the  latter  towns,  which,  according  to  Gordon  and  Hey, 
never  terminated  favourably,  except  when  bleeding  and  purgatives  were 
employed  with  freedom.  But  it  was  not  until  1813,  when  the  inflam- 
matory constitution  had  fully  developed  itself,  and  the  bad  consequences 
arising  from  violent  determination  of  blood  to  the  head  in  nervous  fever 


310  CLINICAL   MEDICINE. 

could  not  be  averted  except  by  decisive  measures^  tliat  venesection 
came  into  general  use  in  Great  Britain  in  consequence  of  a  publication 
by  Dr.  Mills,  who  had  prescribed  it  with  much  success  since  1810. 
In  the  same  year  that  truly  estimable  physician,  Br.  Thompson,  pub- 
lished his  admirable  work  upon  inflammation.  BlackaU  recommended 
blood-letting  in  several  species  of  dropsy,  and  Armstrong  employed 
the  same  remedy,  combined  with  large  doses  of  calomel,  in  the  inflam- 
matory puerperal  fever  which  was  prevalent  in  Sunderland.  Venesection 
became  from  this  time  as  great  a  favourite  as  ever  in  England,  not, 
however,  to  the  exclusion  of  purgatives,  which  were  indicated  by  the 
derangement  of  the  stomach  and  bowels  that  accompanied  the  inflam- 
matory constitution.  Both  these  remedies  were  found  extremely  bene- 
ficial in  the  nervous  fever  which  was  epidemic  in  Ireland  in  1813-14 ; 
its  inflammatory  character  being  clearly  evinced  by  a  hard  and  full  pulse 
during  its  first  stage,  and  a  violent  determination  of  blood  to  the  head, 
by  wliich  the  headache  and  raving  are  increased,  while  its  gastric  type 
was  not  less  strongly  marked  by  tenderness  of  the  epigastrium,  costive- 
ness,  or  else  frequent  and  unnatural  alvine  discharges,  together  with  a 
loaded  tongue  and  bilious  vomiting.  The  latter  symptoms  were,  in  Dr. 
Grattan^s  opinion,  of  such  importance,  that  he  gave  a  decided  pre- 
ference to  the  purgative  plan.  The  fever,  which  had  previously  been 
confined  to  Ireland,  became  generally  difiused  over  the  rest  of  Great 
Britain  after  the  famine  of  1816,  and  continued  without  intermission 
for  four  years.  Its  inflammatory  character  being  pecuHarly  favoured, 
both  in  England  and  Scotland,  by  the  habits  of  the  inhabitants  and 
the  situation  of  these  countries,  venesection  attained  an  unexampled 
degree  of  celebrity,  notwithstanding  the  representations  of  the  Irish 
physicians,  who  used  that  remedy  with  more  moderation.  It  was  soon 
believed  that  there  is  literally  speaking,  no  disease  whatever  in  which 
the  lancet  ought  not  to  be  used,  and,  as  the  human  mind  is  ever  prone 
to  extremes,  it  was  soon  generally  considered,  both  in  England  and 
Scotland,  to  be  a  weU  founded  pathological  inference,  "  there  is  but 
one  species  of  fever,  viz.  the  inflammatory,  and  consequently  venesec- 
tion is  the  only  true  anti-febrile  remedy.  Such  is  the  case  in  England 
at  present,  and  it  must  have  been  so  always,  and  in  every  part  of  the 
world."''  I  flatter  myself,  however,  that  the  preceding  observations  and 
statement  of  facts,  drawn  from  authentic  sources,  sufiiciently  negative 
these  assertions,  and  establish  the  real  existence  of  a  change  in  the 
constitution  of  diseases,  notwithstanding  what  Dr.  Duncan  once  said 
to  me,  "  that  such  changes  existed  only  in  the  imagination  of  phy- 
sicians.^' 

It  is  now  twelve  years  since  Dr.  Autenrieth,  in  his  Account  of  the 


SCAELATINA.  311 

State  of  Medicine  in  Great  Britain,  made  the  foregoing  interesting 
observations ;  and  to  me  it  appears  that  the  history  of  the  diseases 
which  have  since  prevailed  affords  convincing  proofs  that  the  then  in- 
fiammatory  constitution  has  again  subsided,  and  is  now  replaced  by  a 
typhous  type  :  indeed,  it  cannot  be  denied  that  a  very  great  difference 
exists  not  only  between  the  present  and  the  former  scarlatina,  but  also 
between  the  fever  of  the  present  day  and  that  which  prevailed  shortly 
before  Dr.  Autenrieth  published.  But  this  is  too  important  a  question 
for  us  to  decide,  without  more  reflection  and  thought  than  I  have  been 
able  to  bestow  on  it,  and  without  more  facts  than  I  have  been  able  to 
collect.  The  opinion  I  have  brought  forward  I  do  not  wish  to  be  re- 
ceived as  established ;  I  look  upon  it  as  probably  well  founded,  but  as 
yet  not  proved,  except  so  far  as  to  merit  further  consideration  and  excite 
further  discussion. 

Indeed,  I  have  for  the  present  been  obliged,  by  the  pressure  of  other 
engagements,  to  postpone  a  more  accurate  examination  of  this  subject, 
and  a  more  severe  scrutiny  of  the  facts  which  just  now  crowd  into  my  me- 
mory ;  but  I  conclude  with  remarking,  that  the  wide-spreading  epidemic 
of  influenza,  which  in  1833  visited  the  whole  of  Europe,  including  the 
British  Isles,  was  not  only  truly  remarkable,  both  for  the  violence  of 
the  feverish  symptoms  and  of  the  local  congestions  of  the  chest  and 
heart,  which  accompanied  its  attack,  but  likewise  for  the  unexpected 
relation  which  it  was  found  to  bear  to  all  measures  of  active  depletion. 
I  appeal  to  the  profession  for  their  testimony  on  this  matter — I  ask 
whether  all  our  preconceived  opinions  as  to  the  a  priori  indications  for 
venesection,  leeching,  and  purging,  were  not  found  to  be  contradicted 
by  the  effects  of  these  remedies  in  that  epidemic.  The  sudden  manner 
in  which  the  disease  came  on,  the  heat  of  skin,  acceleration  of  the 
pulse,  and  the  intolerable  violence  of  the  headache — together  with  the 
oppression  of  the  chest,  cough,  and  wheezing — all  encouraged  us  to 
the  employment  of  the  most  active  modes  of  depletion,  and  yet  the 
result  was  but  little  answerable  to  our  expectations,  for  these  means 
were  found  to  induce  an  awful  prostration  of  strength,  with  little  or  no 
alleviation  of  the  symptoms.  In  some  who  were  thus  treated,  recovery 
was  protracted  and  doubtful,  and  the  strength  was  not  restored  for 
several  months.  Indeed,  nothing  was  more  curious  than  the  length  of 
time  which  was  necessary  for  some  persons,  in  order  to  recruit  their 
strength  after  an  attack  of  influenza,  although  that  attack  had  not 
continued  more  than  a  few  days,  and  had  been  judiciously  treated, 
witliout  blood-letting  or  unnecessarily  debilitating  remedies.  I  have 
known  some  who  lapsed  into  a  cachectic  state  of  long  continued  debility 
from  which  they  never  recovered ;  for,  while  thus  reduced,  they  fell 


312  CLINICAL   MEDICINE. 

victims  to  the  first  acute  complaint  which  seized  them.  The  influenza 
above  referred  to  fully  confirmed  the  opinion  I  had  long  entertained, 
that  in  acute  diseases  debihty  and  exhaustion  of  the  vital  power  are  by 
no  means  in  every  case  either  caused  by,  or  proportioned  to,  a  state  of 
previous  excitement.  This  opinion  received  further  support  from  the 
symptoms  and  phenomena  exhibited  by  the  Asiatic  cholera,  in  which 
the  stage  of  debility  and  collapse  commenced,  and  too  often  closed  the 
scene ;  and  has  been  still  more  powerfully  corroborated  by  the  epidemic 
of  influenza  of  1837  and  1847,  as  also  by  the  Irish  epidemic  fever  of 
1846-47.  Why  do  I  dwell  upon  these  occurrences,  and  why  have  I 
so  frequently  referred  to  the  opinion  above  expressed  ?  Simply  because 
the  prevalence  of  the  contrary  opinion  laid  the  foundation  for  the  inju- 
dicious and  exclusive  application  of  the  lancet,  and  of  the  antiphlogistic 
method  generally,  in  Great  Britain,  and  was,  consequently,  the  cause 
of  working  excessive  miscliief. 

I  have  already  mentioned  that  the  disease  called  scarlet  fever  assumed 
a  very  benign  type  in  Dublin  soon  after  the  year  1804,  and  continued 
to  be  seldom  attended  with  danger  until  the  year  1831,  when  we  began 
to  perceive  a  notable  alteration  in  its  character,  and  remarked  that  the 
usual  undisguised  and  inflammatory  nature  of  the  attack  was  replaced 
by  a  concealed  and  insidious  form  of  fever,  attended  with  great  debility. 
"We  now  began  occasionally  to  hear  of  cases  which  proved  unexpectedly 
fatal,  and  of  families  in  which  several  children  were  carried  off ;  still  it 
was  not  till  the  year  1834  that  the  disease  spread  far  and  wide,  assum- 
ing the  form  of  a  destructive  epidemic.  The  nature  of  the  disease  did 
not  appear  in  the  least  connected  with  the  situation  or  aspect  of  the 
patient's  dwelling,  for  we  observed  it  equally  malignant  in  Eathmines  as 
in  Dublin,  on  the  most  elevated  habitations  on  mountains  as  in  the 
valley  of  the  Liffey.  It  raged  with  similar  violence  at  Kingstown,  and 
the  neighbourhood  of  Killiney  and  Bray.  The  state  of  the  weather 
seemed  to  exercise  no  influence  either  upon  its  diffusion  or  its  symp- 
toms, which  continued  to  exhibit  equal  virulence,  no  matter  whether  it 
was  wet  or  dry,  warm  or  cold,  cahn  or  stormy.  The  contagion  seemed 
to  act  as  a  more  deadly  poison  on  the  individuals  of  some  families  than 
upon  those  of  others,  and  consequently,  when  one  member  of  a  family 
died,  there  was  always  much  reason  to  fear  for  the  others  when  attacked. 
At  first  I  thought  that  its  greater  severity  in  such  cases  could  be  traced 
to  strumous  habit,  but  subsequent  experience  did  not  confirm  this 
suspicion,  for  the  most  scrofulous  family  I  ever  saw  went  tlirough  the 
disease  without  a  death,  whereas  in  some  others  the  mortality  was  great, 
although  not  a  single  indication  of  a  strumous  diathesis  could  be  de- 
tected.    Many  parents  lost  three  of  their  children,  some  four,  and  in 


SCARLATINA. EPIDEMIC    OF    1834.  313 

one  instance  wliich  came  to  my  knowledge,  five  fine  children  were  car- 
ried off.  As  usual  in  such  epidemics,  the  degree  of  intensity  W'ith  wliich 
different  persons  were  attacked  varied  exceedingly,  some  exhibiting 
the  mildest  form  of  scarlatina  simplex,  which  required  no  treatment, 
and  scarcely  confinement  to  the  room,  while  the  majority  were  severely 
affected.  "When  the  disease  was  violent,  it  assumed  one  or  other  of  the 
following  forms  ; — 

First, — It  at  once  produced  not  merely  fever  with  sore  throat  and 
headache,  but  such  violent  congestion  of  the  brain,  and  determination 
to  the  head,  as  occasioned  convulsions  and  apoplectic  coma  on  the 
first  or  second  day.  This  happened  to  a  young  woman  of  robust 
habit  in  Werburgh-street,  to  wdiom  I  was  called  by  Dr.  Brereton. 
She  was  attacked  with  convulsions  on  the  second  day,  and  died  comatose 
on  the  third.  In  her  the  scarlet  eruption  was  extremely  vivid  and 
general,  a  fact  I  notice  as  a  proof  that  the  congestion  of  internal  organs 
was  not  caused  by  any  retrocession  of  the  eruption.  In  truth,  as  will 
appear  hereafter,  the  worst  cases  had  the  most  general  and  most  intense 
cutaneous  efflorescence.  Wlien  this  tendency  to  the  head  took  place  in 
so  violent  a  manner  at  the  very  outset,  the  patient  was  seldom  saved; 
sometimes,  however,  very  active  measures  of  depletion,  general  and 
local,  relieved  the  brain,  and  the  case  then  w^ent  on  favourably.  This 
happened  in  a  young  gentleman  residing  in  Upper  Baggot-street,  to 
whom  I  was  called  by  the  late  Mr.  Nugent,  of  Merrion-row.  When 
the  scarlet  fever  attacked  a  person  subject  to  epileptic  fits,  the  tendency 
to  the  head  was  increased  by  the  epileptic  habits,  and  fits  of  convulsions 
at  once  supervened.  Thus  in  the  case  of  a  gentleman,  aged  twenty- 
two,  who  had  been  for  several  months  treated  by  Mr.  CoUes  and  me  for 
epilepsy,  the  fits  commenced  on  the  second  day  of  scarlatina,  and  con- 
tinued with  frightful  violence  until  the  fifth  day,  when  they  proved 
fatal.  In  a  young  lady  residing  near  Black  Eock,  to  whom  I  was  called 
by  Dr.  Wilson,  precisely  the  same  thing  occurred.  She  had  been  sub- 
ject to  epilepsy  for  many  years,  and  when  the  scarlet  fever  commenced 
she  was  at  once  seized  with  frequently  recurring  fits,  which  in  spite  of 
the  most  active  measures,  ended  in  fatal  coma  on  the  fifth  day. 

In  the  second  form  of  the  disease  which  I  noticed,  the  symptoms 
were  exceedingly  violent  and  intense  from  the  beginning,  and  the  dis- 
ease set  in  with  the  usual  symptoms  of  severe  exanthematous  pyrexia, 
remarkable  in  the  very  commencement  for  the  violence  of  the  accom- 
panying headache  and  spinal  pains,  and  for  the  great  irritability  of  the 
stomach  and  bowels.  Indeed  one  of  the  very  first  symptoms  in  such 
persons  w^as  nausea,  vomiting,  and  bowel  complaint.  Large  quantities 
of  recently  secreted  bile  were  thrown  up,  and  the  patient  passed  fre- 


314  CLINICAL   MEDICINE. 

quent  stools^   curdled  green  or  saffron  yellow ;  at  first  semi-fluid  and 
afterwards  fluid,  and  evidently  composed  of  bile  suddenly  effused  into 
the  intestinal  canal,  with  a  copious  and  hurried  secretion  of  mucus  from 
the  internal  membrane  of  the  bowels,  and  mixed  with  some  true  fsecal 
matter.     It  was  surprising  what  quantities  were  thus  thrown  up,  and 
passed  from  the  bowels  by  some  individuals  during  the  first  day  or  two 
of  the  disorder;   neither  the  constant  repetition  of  the  nausea,  and 
vomiting,  nor  the  abundance  of  the  discharge  from  the  stomach  and 
bowels,  in  the  shghtest  degree  mitigated  either  the  violence  of  the  fever 
or  of  the  headache,  or  seemed  to  prevent  the  full  formation  of  the  erup- 
tion.    It  was  curious  to  observe  that  this  obstinate  vomiting  and  purg- 
ing was  unaccompanied  by  the  slightest  epigastric  or  abdominal  tender- 
ness ;  during  its  continuance  the  belly  became  fallen  and  soft.     In  fact 
its  cause  was  situated  not  in  the  belly,  but  in  the  brain,  a  fact  I  did  not 
perceive  until  I  had  an  opportunity  of  watching  the  progress  of  five  or 
six  such  cases.     It  depended  on  cerebral  irritation  and  congestion,  and 
was  in  nature  very  similar  to  the  irritabihty  of  stomach  and  bowels 
which  so  often  accompanies,  and  too  frequently  masks  the  progress  of 
acute  hydrocephalus.     As  soon  as  I  had  become  aware  of  the  patho- 
logical relations  of  this  vomiting  and  purging,  I  did  not  confine  my 
endeavours  to  check  these  symptoms  to  measures  intended  to  act  directly 
on  the  stomach  and  bowels,  such  as  effervescing  draughts,  chalk  mix- 
ture, stupes,  leeches  to  the  epigastrium,  &c.,  but  I  changed  my  plan  of 
treatment,  and  turned  my  attention  to  the  state  of  the  cerebral  circula- 
tion.    Having  in  a  former  lecture  referred  to  this  topic,  and  having 
explained  to  you  the  manner  in  which  derangement  of  the  stomach  and 
bowels  of  a  properly  gastric  origin  is  to  be  distinguished  from  disorder 
of  the  digestive  apparatus,  originating  in  a  sympathetic  derangement  of 
function,  itself  caused  by  a  morbid  condition  of  the  brain,  and  having 
already  pointed  out  the  importance  in  practice  of  not  confounding  these 
two  states,  one  or  other  of  which  is  so  common  in  the  commencement 
of  violent  fevers,  phlegmasia,  and  exanthemata,  I  shall  not  at  present 
dwell  any  longer  on  this  subject. 

The  second  form  of  scarlatina  was  likewise  remarkable  for  the  violent 
excitement  manifested  from  the  very  beginning  in  the  circulating  sys- 
tem, and  in  the  production  of  animal  heat.  The  pulse  at  once  rose  to 
above  100,  it  was  seldom  less  than  120,  and  in  many  cases,  particularly 
in  young  people,  it  ranged  from  140  to  150.  I  have  never  in  any 
other  disease  witnessed  so  many  cases  of  excessively  rapid  pulse.  In 
general  the  pulse  in  this  form  was  regular,  but  in  two  cases  it  became 
irregular ;  one  was  that  of  a  gentleman  living  in  Upper  Mount  street, 
whom  I  attended  with  Sir  Henry  Marsh ;  his  pulse  became  intermitting 


SCARLATINA. EPIDEMIC    OF    1834.  315 

and  irregular  on  the  third  day,  and  continued  to  be  thus  affected  more 
or  less  for  about  a  week.  This  gentleman  was  attacked  with  subsultus, 
delirium,  jactitation,  and  various  nervous  symptoms,  at  a  very  early  pe- 
riod, and  complained  constantly  of  his  throat  and  head.  The  former 
was  violently  inflamed,  and  his  skin  was  covered  with  a  bright  red  erup- 
tion. On  the  ninth  day  he  was  seized  with  convulsive  fits  of  great 
violence,  and  which  returned  very  frequently  during  the  night ;  his  case 
appeared  utterly  hopeless,  and  yet  he  perfectly  recovered.  In  a  young 
lady,  who  was  attended  by  Dr.  Nolan,  great  irregularity  and  intermis- 
sion of  the  pulse  commenced  about  the  eighth  day,  and  continued  dur- 
ing the  state  of  danger ;  she  also  recovered.  Of  course  irregularity  of 
the  pulse  was  in  many  not  so  much  a  symptom  of  disease  as  of  ap- 
proaching death,  but  then  the  state  of  the  patient  could  not  be  mistaken, 
judging  from  all  the  other  circumstances  of  the  case.  The  acceleration 
of  the  pulse  abated  in  all  when  an  evident  improvement  in  the  general 
condition  took  place,  but  in  few  did  the  pulse  become  quite  natural  for 
many  days  after  the  favourable  change,  and  in  none  did  it  fall  to  its 
usual  standard  in  the  course  of  twelve  or  twenty-four  hours,  as  it  not 
unfrequently  does  after  the  crisis  of  continued  fevers ;  in  fact,  the  scar- 
latina never  ended  with  a  well-defined  crisis. 

As  to  the  temperature  of  the  body,  I  have  already  observed  that  in 
the  cases  I  am  now  describing  it  was  from  the  first  considerable,  and 
continued  elevated  until  a  very  short  period  before  death.  Both  the 
pulse  and  heat  of  skin,  however,  were  very  easily  reduced  in  energy  by 
the  use  of  the  lancet  or  by  the  repeated  application  of  leeches,  and  it 
was  not  uncommon  to  observe  that  even  the  judicious  use  of  these 
means  induced  a  general  coldness  of  surface,  very  great  sinking  of  the 
strength,  and  a  faltering  state  of  the  pulse.  This  was  remarkably  the 
case  in  a  young  lady  whom  I  attended  along  with  Mr.  Wilkinson,  in 
Black  rock,  and  also  in  one  of  the  family  for  the  history  of  whose  cases 
I  am  indebted  to  Dr.  Nolan.  In  both,  these  effects  were  very  obstinate 
and  alarming,  for  reaction  was  not  restored  until  after  the  lapse  of  more 
than  twelve  hours ;  but  both  finally  recovered.  The  pulse  was  sharp 
but  not  strong,  and  resembled  the  pulse  of  great  irritation  rather  than 
that  of  true  inflammation. 

The  most  distressing  symptom  at  the  commencement  of  this  form 
of  scarlatina  was  the  sore  throat ;  tbe  fauces  were  violently  inflamed, 
and  deglutition  consequently  much  impaired,  while  a  general  soreness 
was  felt  in  the  back  of  the  head  and  neck  ;  urgent  headache  was  com- 
plained of  by  all,  and  from  the  second  day  the  eyes  became  suffused ; 
great  restlessness,  anxiety,  jactitation,  moaning  and  interrupted  raving 
soon  made  their  appearance,  and  in  many,  sleep  was  banished  or  utterly 


316  CLINICAL    MEDICINE. 

broken  by  startings  and  delirium  before  three  or  four  days  had  elapsed. 
The  eruption  had  now  arrived  at  its  height,  which  it  did  with  great  ra- 
pidity, dating  from  the  first  moment  of  its  appearance,  so  that  the  skin, 
everywhere  covered  with  a  scarlet  eruption,  resembled  in  appearance  the 
hue  of  a  boiled  lobster. 

In  these  violent  cases  the  efflorence  was  perfectly  continuous,  and 
never  broken  into  spots  or  patches ;  the  skin  appeared  as  if  evenly 
dyed  with  one  uniform  colour ;  the  surface  of  the  tongue  was  likewise 
much  affected  with  the  same  exanthematous  redness,  and  soon  became 
foul  and  afterwards  dry  and  parched.  The  sudden  drying  of  the  tongue 
on  the  fifth  or  sixth  day  indicated  in  this  form  a  rapid  aggravation  of 
the  disease,  and  death  in  several  cases  was  observed  to  follow  this  change 
in  less  than  twenty-four  hours,  when  it  was,  as  in  a  young  gentleman 
Mr.  Rumley  and  I  attended  in  French-street,  accompanied  by  a  sud- 
den acceleration  of  the  pulse  and  increase  of  the  jactitation  and  deli- 
rium. In  this  form  the  brain  and  nervous  system  seemed  to  be  the 
parts  which  suffered  most,  and  many  became  insensible  for  several  hours 
before  death ;  others  had  convulsions  :  when  the  patient  survived  the 
seventh  day  there  was  a  fair  chance  of  recovery,  but  many,  too  many, 
died  on  the  fourth,  fifth,  or  sixth  days. 

After  I  had  witnessed  a  few  examples  of  this  form  of  scarlatina,  I 
consulted  with  several  of  my  friends  and  colleagues,  and  we  determined 
to  use  the  most  active  measures  of  depletion  in  the  very  first  instance 
that  occurred  to  us.  A  case  was  not  long  wanting.  Sir  Henry  Marsh 
and  I  were  engaged  in  prescribing  for  some  children  labouring  under 
the  epidemic,  in  a  house  in  Pembroke- street,  where  our  attention  was 
directed  to  a  fine  boy,  six  years  old,  and  hitherto  perfectly  healthy,  who 
was,  while  we  were  pa}dng  our  visit,  attacked  with  the  first  symptoms 
of  the  complaint ;  we  immediately  resolved  that  as  soon  as  the  stage  of 
rigor  and  collapse  which  preceded  the  febrile  action  had  passed,  to  visit 
him  again  and  act  energetically,  if  circumstances  seemed  to  permit  it. 
Accordingly  we  came  again  in  the  course  of  a  few  hours,  and  found  re- 
action already  established,  attended  with  vomiting,  purging,  and  head- 
ache. The  sore  throat,  too,  was  much  complained  of,  and  there  was 
great  tenderness  of  the  external  fauces.  We  ordered  relays  of  leeches, 
eight  at  a  time,  to  the  neck,  for  the  purpose  of  relieving  both  the 
throat  and  brain,  and  we  administered  James's  powder  and  calomel  in- 
ternally. On  the  next  day  the  skin  was  burning,  in  spite  of  a  copious 
loss  of  blood  from  the  leech-bites,  the  eruption  vivid  and  already  esta- 
blished, the  pulse  140,  and  there  had  been  little  or  no  sleep.  Relays 
of  leeches  were  again  ordered,  and  persevered  in  until  considerable  and 
lasting  faintness  was  produced,   and  yet  no  impression  seemed  to  be 


SCAULATINA. EPIDEMIC    OF    1834.  317 

the  result,  for  the  raving  became  more  incessant  on  the  second  night, 
and  on  the  third  day  suffusion  of  the  eye  commenced,  and  the  tongue 
became  parched.  Shaving  of  the  head,  the  most  industrious  applica- 
tion of  cold  to  the  scalp,  and  various  other  remedies  were  in  vain  ap- 
plied ;  the  pulse  became  weaker,  the  breathing  quicker,  the  strength 
failed  rapidly,  raving  and  delirium  gave  place  to  insensibility  and  sub- 
sultus,  and  the  patient  died  on  the  fifth  day.  In  this  case  depletion 
was  applied  at  once  and  decidedly,  for  we  blanched  and  weakened  the 
boy  by  loss  of  blood  as  far  as  it  was  possible  to  venture,  and  yet  the 
disease  was  not  in  the  least  degree  checked,  nor  the  symptoms  even  mi- 
tigated. 

A  fine  boy,  thirteen  years  of  age,  was  attacked  in  the  county  of 
Wicklow,  where  he  was  placed  under  the  care  of  a  very  judicious  prac- 
titioner, who  did  not  use  either  venesection  or  leeches,  but  reHed  chiefly 
on  the  exhibition  of  diaphoretics,  particularly  antimonials.  The  boy 
died  on  the  seventh  day,  having  suffered  much  from  dehrium,  subsul- 
tus,  want  of  sleep,  &c.  His  brother,  who  was  one  year  older,  and  a 
very  strong  boy,  was  seized  with  the  disease  in  Dublin,  and  placed  im- 
mediately under  my  care.  I  had  the  advantage  of  Mr.  Eumley's  as- 
sistance, and  we  determined  to  prevent  the  supervention  of  the  cerebral 
symptoms,  if  it  were  possible  to  do  it,  by  means  of  antiphlogistic  treat- 
ment :  we  failed,  and  our  patient  died  on  the  sixth  day.  In  short  this 
form  of  the  disease,  where  the  pulse,  without  becoming  strong,  became 
at  once  extre^nely  rapid,  bore  venesection  badly,  and  required  great 
caution  even  in  the  application  of  leeches ;  the  nervous  symptoms  ap- 
peared only  accelerated  by  the  system  of  depletion,  although  the  heat  of 
the  skin  suggested  its  employment. 

The  derangement  of  the  brain  and  nerves  in  this  form  depended  on 
something  more  than  the  violence  of  the  circulation,  and  originated  in 
something  altogether  different  from  mere  cerebral  inflammation  or  con- 
gestion. What  that  something  was  I  cannot  even  conjecture ;  but  it 
was  probably  the  result  of  an  intense  poisoning  of  the  system  hy  the  ayii- 
mat  miasma  of  the  scarlet  fever.  Every  tissue  of  the  body  seemed,  if 
I  may  use  the  expression,  equally  sick,  equally  overwhelmed,  and  it  is 
probable,  that  the  capillary  circulation  in  every  organ  was  simultaneously 
deranged.  It  was  not  gangrene  of  the  tliroat  which  proved  fatal,  for 
in  this  form  it  never  occurred ;  it  was  not  inflammation  of  any  internal 
viscus,  for  such  was  not  found  on  post-mortem  examination  of  the  fatal 
cases ;  but  it  was  a  general  disease  of  every  part.  In  many,  another 
state  of  things,  which  required  to  be  carefully  distinguished  from  that 
just  described,  existed,  and  the  disease  was  evidently  attended  with  an 
inflammatory  state  of  the  constitution,  requiring  energetic  measures. 


318  CLINICAL   MEDICINE. 

In  such  cases  tlie  symptoms  were  severe  in  the  commencement,  the 
throat  very  sore,  the  efflorescence,  however,  not  quite  so  sudden  or  so 
perfect,  and  the  pulse  not  so  quick,  never  excessively  rapid,  and  always 
strong  and  distinct.  Such  bore  bleeding  and  leeching  well,  and  ex- 
perienced from  their  use  almost  immediate  alleviation  of  the  sore  throat, 
headache,  and  restlessness,  and  were  not  much  weakened  by  the  deple- 
tion. It  must  be  confessed,  that  it  was  often  exceedingly  difficult  to 
determine,  a  priori,  whether  the  depletory  system  ought  or  ought  not  to 
be  tried.  Where  doubt  existed,  my  custom  was  to  try  moderate  leech- 
ing, and  from  its  effects  I  judged  of  the  propriety  of  persevering. 

The  disease  very  frequently  occurred  in  a  third  fornix  more  singular 
still  than  the  two  first,  and  much  more  insidious  in  its  commencement. 
This  form  was  evidently  very  common  in  the  epidemic  scarlet  fever  de- 
scribed by  Withering,  as  cited  by  Dr.  Tweedie.  In  this  form  the  disease 
was  ushered  in  by  the  usual  symptoms  of  pyrexia,  together  with  sore 
throat,  shght  headache,  and  in  due  time  a  very  moderate  and  normal 
eruption.  The  symptoms  continued  moderate;  the  patients,  after  the 
first  few  days,  slept  tolerably  well  during  the  night,  had  no  raving,  and 
were  quiet  during  the  day.  About  the  fourth  or  fifth  day  all  the  febrile 
symptoms  had  so  far  subsided,  that  a  most  accurate  examination  could 
detect  nothing  urgent,  nothing  in  the  slightest  degree  either  alarming  or 
calculated  to  excite  the  least  anxiety  in  the  patient's  condition.  His 
skin  became  nearly  of  the  natural  standard,  his  thirst  diminished,  and 
the  pulse  was  now  scarcely  accelerated ;  a  calm  nearly  complete,  in  fact, 
seemed  to  have  followed  the  first  onset  of  the  disease ;  and  on  entering 
the  room,  the  physician  might  easily  be  deceived,  as  I  myself  was  more 
than  once,  into  the  pleasing  hope,  that  aU  danger  was  past,  and  that 
perfect  recovery  might  confidently  be  anticipated. 

This  hope  was,  in  truth,  founded  on  such  circumstances  as  we  can 
usually  rely  on ;  for  who  would  prognosticate  danger  where  his  little 
patient,  sitting  up  in  bed,  and  perhaps  eating  a  dry  crust  with  some 
appetite,  had  a  placid  countenance,  and  had  enjoyed  a  night  of  tranquil 
sleep  ?  Regular  alvine  evacuations,  diminution  of  thirst,  sore  throat, 
headache,  and  fever,  together  with  the  normal  state  of  the  cutaneous 
eruption,  all  conspired  to  confirm  a  favourable  prognosis ;  and  so  matters 
proceeded,  the  family  dismissing  all  apprehensions  as  to  the  result,  and 
the  physician  most  probably  discontinuing  his  attendance  about  the 
seventh  day,  in  the  belief  that  aU  danger  was  over,  and  that  his  inter- 
ference was  no  longer  necessary.  Matters  proceeded  thus  until  the 
eighth  or  ninth  day,  when  a  certain  degree  of  restlessness  was  observed 
to  occur,  and  in  the  morning  a  slight  return  of  fever  might  be  noticed. 
Then  it  was  that  a  pecuUar  train  of  symptoms  set  in.     The  nostrils  as- 


SCARLATINA. EPIDEMIC    OF    1834.  810 

sumed  a  sore  and  irritated  appearance  about  the  edge  of  the  alse,  and  a 
serous  moisture  began  to  flow  from  their  internal  cavities.  Sore  throat 
was  again  complained  of,  the  skin  became  hot,  great  debility  and  pros- 
tration of  strength  came  on  suddenly,  a  painful  tumefaction  commenced 
in  the  region  of  the  parotids  and  submaxillary  glands.  This  tumefaction 
increased  rapidly,  becoming  every  day  harder,  more  elevated,  diffused, 
and  exceedingly  tender,  but  without  much  redness.  In  the  course  of  a 
few  days  it  surrounded  the  neck  like  a  collar,  and  being  attended  with 
swelling  of  the  face,  the  poor  little  patient's  countenance  was  sadly  dis- 
figured. In  the  mean  time  the  discharge  from  the  nose  had  increased 
considerably,  and  become  more  viscid  and  fetid ;  the  internal  membrane 
lining  the  nasal  passage  was  affected  throughout,  its  entire  surface  every- 
where inflamed  and  tumefied,  so  that  a  snuffling  sound  was  produced 
when  the  patient  breathed  through  his  nose :  at  length  the  discharge 
increased  to  such  a  degree,  that  the  nostrils  became  completely  imper- 
vious to  the  air  in  breathing.  The  state  of  the  throat  generally  began 
to  alter  for  the  worse  at  the  very  commencement  of  this  change ;  and  a 
similar  inflammation,  attended  with  an  ill-conditioned  secretion  of  lymph 
and  fluid,  occupied  the  entire  surface  of  the  mouth  and  tongue,  and  at 
last  spread  deeply  into  the  pharynx. 

While  this  was  going  on,  the  fever  freshly  lit  up,  at  once  exhibited 
the  most  decided  symptoms  of  the  worst  form  of  typhus  and  subsultus, 
constant  muttering,  raving,  anxiety,  want  of  sleep,  restlessness,  moaning 
mingled  with  an  occasional  screech,  reminding  one  of  that  which  is  so 
ominous  in  hydrocephalus.  Great  difficulty  was  now  experienced  in 
swallowing,  and  the  drink  was  frequently  spurted  out  of  the  mouth  after 
a  vain  attempt  at  deglutition.  Matters  now  proceeded  rapidly  from 
bad  to  worse,  and  at  last,  after  much  suffering,  death  closed  the  scene, 
being  preceded  for  many  hours  by  a  state  of  extreme  restlessness,  during 
which  it  was  imposible  to  determine  whether  the  patient  was  still  sensi- 
ble. The  swelling  of  the  neck  went  on  increasing  to  the  last,  but  sel- 
dom exhibited  any  tendency  to  point ;  it  continued,  on  the  contrary, 
every  where  hard,  or,  at  most,  became  indistinctly  softened,  or,  to  use  a 
technical  phrase,  "  boggy.''  "When  cut  into,  no  matter  was  found ; 
blood,  serum,  and  a  diffused  cellular  slough,  not  separated  from  the 
living  tissues,  were  observed  on  making  the  incision. 

Some  notes  on  this  epidemic  I  received  from  Mr.  O'Perrall,  are  ex- 
tremely valuable,  more  especially  where  he  describes  a  most  important 
sequela  of  scarlatina  not  liitherto  mentioned  by  any  writer;  I  shall 
therefore  give  you  a  brief  statement  of  his  observations. 

"  Of  seventeen  cases,"  says  he,  "  of  which  I  possess  notes,'  four  oc- 
curred in  adults,  three  in  children  under  four  years  of  age,  and  the  re- 


320  CLINICAL  MEDICINE. 

mainder  at  different  ages  between  the  latter  and  fourteen  or  fifteen  years. 
I  seldom  saw  the  cases  in  the  commencement.  The  mode  of  attack  was 
occasionally  similar  to  that  of  common  sore  throat  followed  by  rigors  ; 
sometimes  violent  pyrexia  and  shiverings,  with  intolerable  headache^  and 
even  delirium^  preceded  by  other  signs.  In  some  few  cases,  the  efflor- 
escence first  attracted  notice,  the  fever  in  these  instances  being  through- 
out so  mild  as  scarcely  to  demand  attention. 

"  The  progress  of  the  disease  was  various,  but  usually  bore  a  relation 
to  the  character  of  the  incipient  fever.  In  general,  the  fever  increased 
in  intensity  as  the  disease  advanced,  or  as  new  parts  became  engaged ; 
but  this  was  not  always  the  case.  In  two  instances,  which  I  saw  in  a 
state  of  great  vital  depression  on  the  third  or  fourth  day,  I  was  assured 
that  the  early  fever  was  very  high,  although  it  had  passed  rapidly  into 
the  typhoid  state. 

"  The  danger  sometimes  appeared  to  arise  from  the  condition  of  the 
entire  system,  sometimes  from  that  of  important  parts.  Of  two  cases 
which  I  saw  when  dying,  one  was  sinking  like  a  person  in  typhus  fever  ; 
the  other,  a  boy  thirteen  years  old,  was  moribund  in  the  coma,  which 
succeeded  to  violent  phrenitic  delirium.  The  latter  case  was  remarkable 
in  this,  that  the  phrenitic  state  occurred  while  the  eruption  was  in  its 
prime,  the  whole  body  retaining  its  deep  scarlet  colour  until  a  short  time 
before  his  death.  The  disease  in  this  instance  set  in  with  delirium 
which  had  been  subdued,  I  have  reason  to  believe,  by  the  most  active 
means.  Death  occurred  in  one  instance  from  croup,  the  disease  of  the 
throat  having  passed  into  the  trachea  and  bronchial  tubes.  In  another, 
sloughing  of  the  fauces,  with  low  fever,  carried  off  the  patient  on  the 
sixth  day. 

"  In  several,  who  ultimately  recovered,  life  was  seriously  endangered 
by  local  inflammatory  attacks.  In  one  instance,  a  girl  about  seven 
years  old,  enteritic  symptoms  sprang  up  suddenly  while  the  patient  was 
in  a  very  weak  state,  and  were  with  difficulty  subdued.  In  another,  a 
boy  ten  years  old,  acute  pain  in  the  region  of  the  heart  occurred  when 
the  eruption  was  on  the  decline ;  it  was  accompanied  by  short  cough, 
palpitations,  dyspnoea,  rapid,  though  not  irregular  pulse,  and  sudden 
accession  of  fever.  There  was  no  ^&[CQ^i^}o\e,frottement,  but  the  action 
of  the  heart  was  violent,  and  there  was  acute  pain  on  pressure.  It 
yielded  to  leeching,  followed  by  calomel,  with  Jameses  powder,  till  the 
gums  were  sHghtly  touched. 

"Another  patient,  a  girl  twelve  years  old,  narrowly  escaped  the 
effects  of  sloughing  of  the  tliroat.  Croup  occurred  in  two  instances, 
in  wliich,  notwithstanding  the  opinions  of  M.  Trousseau,  I  could  not 
doubt  its  origin  in  scarlatina.     It  happened,  no  doubt,  in  cases  wliich 


SCARLATINA. EPIDEMIC    OF    1834.  321 

had  exhibited  the  diphtheritic  patches,  without  much  surrounding  inflam- 
raation  on  the  tonsils,  but  the  eruption  was  sufficiently  marked  to  re- 
move all  obscurity.  One  child,  who  recovered,  ejected  the  false  mem 
brane  (which  I  still  preserve)  in  a  tubular  form,  and  presenting  a  cast 
of  the  trachea  a  little  beyond  its  bifurcation.  In  the  cliild  before  men- 
tioned, who  died,  patches  of  false  membrane  were  also  ejected ;  but  she 
sank  exhausted,  and  the  disease  was  afterwards  discovered  to  have  ex- 
tended far  into  the  bronchial  ramifications. 

"  Although  the  treatment  was  generally  antiphlogistic,  this  plan  was 
not  always  applicable,  even  in  the  commencement  of  the  disease.  In  all 
instances  which  I  had  an  opportunity  of  observing,  it  was  necessary  to 
watch  the  effects  of  local  bleeding.  It  was  easy  to  pass  the  boundary 
of  reHef,  and  then  most  difficult  to  repair  the  loss,  and  meet  the  symp- 
toms of  exhaustion  when  they  had  actually  set  in.  Wine  and  diffusible 
stimuli  were  often  required  from  this  cause  alone,  even  when  the  cases 
had  nothing  of  the  malignant  or  typhoid  character  in  their  nature. 

"  Tepid  sponging  appeared  in  many  instances  preferable  to  cold,  and 
I  think  the  soothing  effects  were  of  longer  duration.  Reaction,  and  the 
distressing  sense  of  burning  heat,  did  not  appear  to  recur  so  soon  as 
when  cold  fluids  were  employed.  Purgatives,  except  of  the  mildest 
kind,  were  not  well  borne,  but  cooling  diuretics  were  clearly  indicated, 
and,  when  persevered  in,  had,  in  many  cases,  the  apparent  effect  of  an- 
ticipating the  sequelae  of  the  complaint. 

"  The  ulcerations  and  slougliings  of  the  throat  were  treated  by  nitrate 
of  silver,  alum,  and  the  chlorides,  according  to  their  states.  But  none 
of  these  applications  were  to  be  depended  on,  when  the  colour  of  the 
fauces  was  intensely  red,  unless  a  few  leeches  had  been  previously 
applied.  In  one  gentleman,  twenty-eight  years  of  age,  free  leeching, 
externally,  (to  the  number  of  forty)  failed  in  removing  the  sense  of  suf- 
focation or  enabling  him  to  swallow.  A  few  leeches  applied  to  the 
inside  of  the  nostrils  was  followed  by  copious  bleeding  and  immediate 
relief.  The  latter  expedient  was  indicated  by  the  tumid  state  of  the 
velum  and  pituitary  membrane,  the  stertorous  breathing,  and  complete 
occlusion  of  the  nares. 

"Its  mode  of  spreading  in  famihes  was  uncertain.  It  sometimes 
attacked  children  witliin  a  few  days  of  each  other  :  at  other  times,  a 
fortnight  has  elapsed  before  I  was  again  requested  to  see  a  new  patient. 
Some  children  escaped  the  disease  altogether. 

*^  Among  the  sequelae  which  I  had  occasion  to  see,  diarrhoea  occurred 

in  two  or  three  instances,  chronic  bronchitis  in  one,  and  anasarca  in  four. 

The  urine  was  shghtly  albuminous  in  two  of  the  latter  cases  before  the 

face  and  limbs  began  to  swell ;  in  the  other  two  it  exhibited  this  cha- 

VOL.  I.  21 


322  CLINICAL   MEDICINE. 

racter  when  the  disease  was  formed,  but  I  did  not  see  them  previously. 
The  treatment  of  the  anasarca  was  antiphlogistic  and  diuretic,  and  suc- 
ceeded in  restoring  three  to  perfect  health ;  the  fourth  still  remains  an 
invalid,  but  not  from  this  cause ;  the  apex  of  the  right  lung  affords 
evidence  of  tubercular  disease. 

"  I  have  now  to  mention  a  peculiar  affection  of  the  neck,  which  I 
have  not  before  seen  in  connexion  with  scarlatina,  but  of  which  four 
cases  have  occurred  during  my  observation  of  the  epidemic  in  question. 

"  Case  1. — About  the  beginning  of  August,  1834, 1  was  requested  by 
my  friend.  Dr.  Davy,  to  see  a  young  girl,  ten  years  old,  in  Upper  Bag- 
got  street.  Her  convalescence  was  tedious,  some  degree  of  fever  still 
existing  at  the  end  of  six  weeks  from  the  commencement  of  the  attack. 
But  her  principal  complaint  was  severe  pain  of  the  right  side  of  the 
neck,  close  to  the  head,  and  extending  as  high  as  the  vertex  on  the  least 
motion  of  the  part.  She  could  not  raise  her  head  from  the  pillow 
without  putting  a  hand  at  each  side  for  its  support,  and  when  taken 
out  of  bed,  instinctively  sought  a  resting-place  for  the  chin.  The  face 
was  awry,  its  vertical  diameter  passing  from  above  downwards,  and  from 
right  to  left.  Posteriorly,  the  upper  cervical  vertebrae  were  curved,  the 
convexity  of  the  curve  being  situated  a  little  to  the  left  of  the  middle 
line  :  there  was  considerable  swelling  of  the  soft  parts  covering  the 
bones.  Pressure  here  was  intolerable,  and  the  least  attempt  to  rotate 
the  head  occasioned  severe  pain.  Deglutition  was  now  tolerably  easy, 
but  there  had  been  considerable  difficulty  of  swallowing  during  the 
early  period  of  the  complaint.  There  was  here  obviously  a  carious  state 
of  the  articulation  of  the  atlas  and  dentata,  and  we  did  not  expect  to 
remove  the  curvature.  Perfect  rest  was,  however,  enjoined,  and  the 
usual  remedies  employe^  with  a  view  to  arrest  the  further  progress  of 
the  disease.  She  gradually  recovered  her  health,  and  is  now  lively  and 
well  grown,  but  the  curvature  is  permanent. 

"  Case  2. — Early  in  August,  1834,  Mary  Inglesby,  of  Eussell  Place, 
aged  7,  was  sent  to  me  by  Mr.  Long,  of  Summer  Hill.  She  was  con- 
fined to  bed  in  scarlatina  for  a  fortnight.  At  the  end  of  this  time  she 
was  taken  out  of  bed,  and  then  the  head  was  observed  to  be  turned  to 
one  side.  It  was  now  five  weeks  altogether  from  the  beginning  of  the 
disease,  and  the  parts  were  still  in  the  same  state.  The  face  was  awry. 
She  complained  of  pain  in  the  concavity  of  the  curve  and  that  side 
of  the  head,  and  could  not  bear  the  slightest  motion  or  shock.  Leeches 
were  prescribed,  and  calomel  given  afterwards  in  doses  of  a  grain,  three 
times  a  day,  till  the  gums  were  touched.  As  soon  as  this  effect  was 
produced,  the  pain  subsided,  and  the  head  gradually  acquired  its  natural 
position.     Her  recovery  was  complete. 


SCARLATINA. EPIDEMIC    OF    1834.  323 

^' Case  3. — A  younger  brother  of  Mary  Inglesby  was  subsequently 
under  the  care  of  Mr.  Long^  for  scarlatina.  The  same  stfite  of  the  head 
and  neck  were  detected  on  the  thirteenth  day,  and  treated  by  Mr.  Long 
on  the  same  plan  as  that  adopted  in  the  former  case.  The  pain  dis- 
appeared as  soon  as  the  mouth  was  made  sore,  and  the  position  of  the 
head  became  natural.     He  is  now  in  good  health. 

"Case  4. — I  met  Mr.  Edgar  of  Arran  Quay,  in  February,  J 835,  in 
the  case  of  a  young  gentleman  about  six  years  old,  whose  convalescence 
from  scarlatina  was  tedious,  and  in  whom  the  difficulty  of  swallowing 
persisted  after  the  redness  of  the  fauces  was  removed.  On  taking  him 
out  of  bed  it  was  remarked  that  he  was  quite  unable  to  keep  the  head 
erect.  The  symptoms  were  similar  to  those  of  the  two  last  cases,  but 
in  a  milder  degree.  A  few  leeches  were  applied,  and  evaporating  lotions 
instantly  used  to  the  part,  on  account  of  considerable  local  heat.  The 
leeching  was  repeated  in  a  day  or  two,  but  as  the  symptoms  yielded 
rapidly,  and  as  he  had  some  tendency  to  diarrhoea,  calomel  was  not  em- 
ployed. In  about  a  fortnight,  the  natural  position  of  the  head  and 
neck  was  restored. 

"  I  can  offer  no  better  explanation  of  the  occurrence  of  tliis  affection, 
during  the  progress  of  scarlatina,  than  by  supposing  that  the  inflam- 
mation of  the  fauces  and  back  of  the  pharynx  was  propagated  to  the 
adjoining  parts.  In  all  these  cases  there  had  been  marked  and  pro- 
longed difficulty  of  deglutition,  as  a  symptom  of  the  disease ;  and  it  is 
to  this  circumstance  I  am  desirous  of  calling  attention,  as  affording  an 
index  for  a  careful  review  of  the  condition  of  the  spine  during  the 
period  of  convalescence.  Should  a  child  be  observed  to  lie  more  on 
one  side  than  the  other,  and  evince  an  unwillingness  to  be  disturbed,  it 
would  be  an  additional  reason  for  suspecting  a  tendency  to  this  com- 
plaint.'^ 


324 


LECTUEE  XXIII. 

SCARLATINA. ^ITS    DIFFUSION     AND     TYPE     IN    THE    COUNTRY    DISTRICTS 

OF    IRELAND. 

Since  the  preceding  Lecture  was  delivered,  scarlatina  has  raged  every 
winter  and  spring  with  undiminished  virulence,  resisting,  as  before, 
nearly  every  kind  of  treatment,  until  the  last  two  years,  1847  and  1848, 
when  it  was  much  less  severe  both  in  extent  and  character,  and  con- 
sequently much  less  fatal.  A  letter  which  I  received  in  1842  from  Dr. 
Gumming,  of  Armagh,  stating  that  scarlatina  had  rarely  been  witnessed 
in  that  city  since  he  settled  there,  eleven  years  previously,  and  that  he 
had  never  seen  the  malignant  form  of  the  disease,  induced  me  to  for- 
ward a  circular  to  the  principal  medical  men  in  the  provinces,  to  ascer- 
tain if  the  disease  prevailed  in  their  respective  districts,  and  if  it 
had  assumed  the  fatal  form  we  had  observed  in  so  many  instances  in 
Dublin. 

I  shall  now  briefly  state  the  principal  facts  contained  in  the  answers 
to  my  queries.  Dr.  Geoghegan,  of  Kildare  Infirmary,  says,  that  during 
his  residence  there  ,  for  ten  years,  scarlatina  never  prevailed  as  an  epi- 
demic, and  the  sporadic  cases  he  met  with  were  exceedingly  mild,  until 
just  about  the  period  of  the  receipt  of  my  letter,  w^hen  many  cases  of  it 
occurred  at  Newbridge,  four  miles  from  his  residence,  on  the  Dublin 
road,  and  to  judge  from  the  number  and  rapidity  of  the  deaths,  of  the 
malignant  kind.  It  was  nearly  confined  to  'the  children  of  the  labour- 
ing class,  but  not  having  the  dispensary  there,  he  did  not  see  them. 
One  case,  however,  which  he  did  attend,  that  of  a  boy,  aged  five  years, 
then  three  weeks  iU,  he  describes  as  foUows  : — On  the  right  temple  was 
a  large  ecchymosis,  about  two  inches  in  diameter ;  arterial  blood  trick- 
ling from  the  nose,  mouth,  and  ears ;  he  was  greatly  emaciated,  and 
quite  sensible,  had  diarrhoea  and  the  hemorrhage  only  from  the  preced- 
ing day ;  the  cervical  glands  were  enlarged,  but  had  not  suppurated, 
nor  was  there  anasarca  or  dropsy ;  he  died  the  following  morning. 

Dr.  Astle,  of  Edenderry,  does  not  remember  its  occurrence  as  an  epi- 
demic, and  the  sporadic  cases  he  has  seen  have  been  mild.     Dr.  Wood- 


SCARLATINA.  325 

ward,  of  Kells,  has  not  seen  it  epidemically,  but  isolated  cases  were  re- 
markably fatal,  some  dying  within  the  first  twenty-four  hours.  Dr. 
CHfFord,  of  Trim,  mentions  that  it  has  latterly  been  prevalent  in  his 
district  and  very  fatal.  Dr.  Clarke,  of  Eathdrum,  states  that  it  has 
been  on  the  increase  for  the  last  three  years,  but  has  been  very  mild. 
Dr.  Lloyd,  of  Malahide,  says,  "  In  reply  to  your  circular  relative  to 
the  prevalence  of  scarlatina  in  my  district,  I  beg  to  say,  the  year  end- 
ing May,  1839,  no  case  occurred;  May,  1840,  one  case  in  an  adult; 
May,  1841,  no  case;  May,  1842,  thirty-two  cases  are  registered,  three 
of  which  were  fatal,  one  24  hours  after  the  appearance  of  the  eruption ; 
the  others  were  a  brother  and  sister,  aged  eight  and  six,  scrofulous, 
and  after  a  period  of  from  12  to  16  days,  they  died  of  diseased  brain 
and  abscesses  in  the  throat.  Since  May,  up  to  this  date,  (August  20, 
1842),  six  cases  have  been  under  my  care.  The  only  cases  of  moment 
were  those  mentioned  above  as  fatal,  and  some  of  the  same  family  in 
which  the  urgent  symptoms  were  extensive  ulceration  of  the  fauces — 
they  recovered  rapidly.  During  the  past  year,  there  were  numerous  in- 
stances of  the  disease,  but  so  slight  that  the  individuals  were  under  no 
restraint ;  so  that  I  was  not  applied  to,  save  occasionally  to  treat  some 
of  the  sequelae.  I  may  here  allude  to  a  curious  fact.  My  district  joins, 
on  one  side,  that  of  Baldoyle ;  on  the  other.  Swords ;  in  both,  epi- 
demic diseases  have  frequently  appeared  for  the  last  25  years,  with  viru- 
lence, and  after  a  long  period  commenced  in  Malahide  district,  in  a  mild 
and  subdued  form :  many  of  the  poor  inhabitants  are  aware  of  the 
circumstance.^^ 

Dr.  Glover,  of  Philipstown,  never  saw  or  heard  of  a  case  of 
scarlatina  during  the  four  years  he  has  resided  there.  Dr  Brunker, 
of  Dundalk,  mentions,  that  the  disease  has  only  presented  itself 
in  one  instance  within  the  last  five  years,  and  was  very  mild.  Dr. 
Hudson,  of  JN'avan,  has  not  met  with  the  disease  often ;  and  during  a 
term  of  eight  years  has  only  had  one  fatal  case ;  Whilst'  Dr.  Byron  of 
the  same  town  states,  that  the  disease  "  was  very  prevalent,  and  in  seve- 
ral localities  unusually  malignant  during  the  last  two  years,  up  to  a 
period  of  about  two  months  ago,  when  it  was  observed  to  be  on  the  de- 
cline. At  present  there  are  very  few  cases  within  twelve  or  fifteen  miles 
of  Navan,  and  these  are  less  virulent,  generally  speaking,  than  formerly/' 
From  Wexford,  Dr.  Boxwell  writes,  that  there  '^  they  have  had  but  a 
few  scattered  cases  in  the  town  for  the  last  six  years,  and  not  one  fatal." 
In  Arklow,  Dr.  Wright  mentions,  that  scarlatina  has  been  very  preva- 
lent in  that  town  and  neighbourhood  for  several  years  past,  particularly 
1840-41 ;  but  it  did  not  frequently  prove  fatal/'  In  Athy,  as  appears 
from  the  letter  of  Dr.  Clayton,  it  has  prevailed,  and  some  of  the  cases 


326  CLINICAL   MEDICINE. 

have  proved  fatal.  Dr.  Macartney,  of  Emiiscortliy,  states,  that  it  was 
prevalent  and  fatal  during  1837  and  1838,  and  that  it  was,  at  the  time 
of  writing,  breaking  out  again. 

The  communication  of  Dr.  Ridley,  of  Tullamore,  I  will  read  at  length. 

"  Scarlatina,"  he  writes,  "  appeared  here  in  the  latter  part  of  No- 
vember, as  an  epidemic,  and  continued  to  be  very  prevalent  until  June 
following.  During  this  period  it  prevailed  most  in  the  month  of 
March.  I  saw  a  great  number  of  cases  in  this  town  and  the  neigh- 
bourhood, which  were  mostly  all  of  the  benign  or  simple  form.  Some 
cases  occurred,  in  full  plethoric  subjects,  of  an  inflammatory  nature ; 
but  I  did  not  meet  with  a  case  of  the  malignant  or  typhoid  disease, 
such  as  I  have  seen  in  Dublin.  This  epidemic  raged  chiefly  amongst 
children  and  young  people — the  oldest  subject  I  am  aware  of  having 
had  it  was  a  person  of  forty  years.  It  commenced  with  rigors,  lassi- 
tude, loss  of  appetite,  (in  some  cases  with  ^soreness  of  the  throat  as  a 
first  symptom),  and  the  usual  symptoms  of  approaching  fever,  which 
continued  to  increase  until  the  third  or  fourth  day,  during  w^iich  time, 
in  some  instances,  the  fever  ran  high,  with  raving  and  other  symptoms 
of  cerebral  disturbance.  The  eruption  generally  appeared  on  the  se- 
cond day  in  the  form  of  small  distinct  spots  like  flea-bites,  which  did 
not  run  together,  and  declined  suddenly  on  the  fourth  or  fifth  day  with- 
out desquamation.  In  some  instances  the  character  of  the  eruption 
was  an  efflorescence,  which  remained  out  until  the  sixth  or  seventh  day, 
and  was  followed  by  desquamation.  The  fever  was  equally  high  in 
both  these  forms  of  eruption,  but  of  greater  duration  in  the  latter. 
The  tiiroat  was  very  slightly  affected  in  the  majority  of  cases,  being  no- 
thing more  than  a  sliglit  erythematous  blush  on  the  velum  and  tonsils  ; 
however,  in  some  robust,  plethoric  persons,  there  was  much  inflamma- 
tion, demanding  active  treatment.  The  symptoms  had  usually  so  much 
subsided  as  to  enable  the  patient  to  leave  the  bed  on  the  sixth  or  seventh 
day.  The  fatal  cases  wliicli  I  witnessed  here,  were  caused  by  congestion 
of  the  brain,  occurring  on  the  third  day,  while  the  eruj)tion  was  well  out 
and  every  thing  a;ppeared favourable,  slight  drowsiness  set  in,  which  was 
quicJcly  follovjed  by  coma  and  stertor  ;  and  in  two  cases  death  ensued  in 
tliirty  hours  from  the  commencement  of  these  symptoms  :  they  were  all 
in  young  persons  of  full  habit,  who  had  no  previous  delhium  or  inflam- 
matory affection  of  the  brain.  The  sequelae  were,  anasarca,  (which  was 
very  general,  and  occurred  after  the  mildest  form  of  the  disease),  pneu- 
monia, bronchitis,  acute  rheumatism,  remittent  fever,  and  enlargement 
of  the  submaxillary  and  parotid  glands.  In  one  instance  pneumonia 
proved  fatal  in  eighteen  hours.  It  was  the  case  of  a  boy  nine  years  old, 
Avho  had  been  three  weeks  recovered  from  scarlatina.     The  treatment 


SCARLATINA.  327 

was  that  usually  practised.  Emetics  and  purgatives,  diaphoretics,  at- 
tending to  ventilation,  &c.,  were  sufficient  in  the  generality  of  cases. 
In  the  inflammatory  form,  venesection,  antimonials  and  calomel  were 
prescribed ;  when  the  throat  was  affected,  the  free  application  of  nitrate 
of  silver  was  found  to  be  the  best  remedy.  Leeches,  acid  gargles,  ap- 
plication of  powdered  alum,  blisters,  &c.,  were  also  beneficial.  When 
anasarca  followed,  it  generally  yielded  to  smart  hydragogue  purgatives ; 
but  in  some  cases  I  gave  calomel  and  squill  with  advantage  :  as  a  pro- 
phylactic I  was  induced  to  try  belladonna,  but  without  success. 

"There  was  at  this  time  a  very  prevalent  inflammatory  affection  of  the 
tliroat,  which  appeared  and  disappeared  with  the  scarlatina.  This  dis- 
ease commenced  with  slight  fever,  stiffness  of  the  neck  and  dysphagia, 
which  afterwards  increased  to  a  great  degree.  The  pharynx,  tonsils, 
and  velum  assumed  a  deep  scarlet  hue,  and  were  in  some  cases  covered 
with  patches  of  lymph,  which  could  be  raised  off  with  a  probe,  like  the 
membrane  of  diphtherite.  The  tonsils  became  greatly  enlarged;  also 
the  parotid  and  submaxillary  glands  :  the  jaw  became  fixed,  so  that  the 
teeth  could  not  be  separated ;  thcH"e  were  inability  of  swallowing,  hurried 
breathing,  and  high  fever.  These  symptoms  increased  to  the  fourth  or 
fifth  day,  when  the  fever  subsided  with  diaphoresis ;  the  jaw  became 
relaxed,  copious  salivation  came  on,  and  the  abihty  of  swallowing  was 
ill  some  degree  restored ;  and,  finally,  in  the  course  of  eight  or  nine 
days  from  the  commencement  of  the  attack,  this  inflammation  ended  in 
resolution.  In  some  few  cases  one  or  both  tonsils  suppurated,  and  in 
other  still  rarer  instances,  ulceration  of  the  pharynx  followed.  Such 
are  the  symptoms  of  the  most  severe  form  of  this  disease ;  but  it  was 
sometimes  so  mild,  as  not  even  to  confine  patients  to  the  house. 

"  At  any  other  time  this  disease  w^ould  have  been  looked  on  merely 
as  an  epidemic  cynanche ;  but  in  this  instance,  there  was  a  very  decided 
connexion  observed  between  it  and  the  prevailing  scarlatina.  It  was, 
in  the  first  place,  even  popularly  remarked,  that  a  person  who  had  suf- 
fered from  this  cynanche  had  not  been  afterwards  attacked  with  scarla- 
tina, and  that  an  attack  of  the  latter  was  not  in  any  instance  followed 
by  one  of  the  former.  It  was  likewise  observed,  that  when  one  mem- 
ber of  a  family  was  seized  with  cynanclie,  scarlatina  soon  showed  itself 
amongst  some  of  the  rest ;  and  in  the  same  manner,  when  scarlatina 
appeared  first,  cynanche  very  frequently  followed,  so  that  one  was  con- 
sidered the  forerunner  of  the  other.  The  following  few  brief  cases 
may  serve  to  show  this  connexion. 

"Case  1. — Master  S.  came  home  from  school  (where  scarlatina  had 
prevailed),  complaining  of  soreness  in  swallowing,  shght  headache,  and 
nausea.     The  next  day  the  tonsils  were  enlarged,  and  he  complained  of 


328  CLINICAL   MEDICINE. 

greater  pain  in  swallowing ;  pulse  quick,  skin  Lot ;  hut  no  appearance 
of  eruption.  These  symptoms  remained,  not  getting  worse,  for  three 
days,  when  they  gradually  subsided.  Before  he  was  perfectly  well, 
scarlatina  seized  two  of  his  sisters  and  his  father.  In  the  former,  the 
eruption  appeared  as  an  efflorescence  and  ended  in  desquamation ;  in 
the  latter  it  was  in  the  form  of  distinct  spots,  and  without  any  subse- 
quent desquamation. 

*^  Case  2. — Master  0.  came  home  from  the  same  school  with  scarla- 
tina. Two  of  his  sisters  and  his  brother  were  seized  with  it  while  he 
was  ill.  The  eruption  came  out  well  in  the  spotted  form.  At  the  same 
time  the  man  and  maid-servant  were  attacked  violently  with  cynanche, 
which  was  attended  with  high  fever  for  several  days. 

"Case  3. — Visited  Mr.  B,  who  had  been  suffering  from  severe 
cynanche  for  four  days.  He  cannot  articulate  or  swallow ;  the  jaw  is 
so  fixed  as  to  prevent  the  teeth  being  separated  to  more  than  a  quarter 
of  an  inch ;  fresh  tumefaction  of  the  neck ;  pulse  quick ;  skin  hot  and 
dry ;  breathing  hurried ;  face  swollen  and  flushed ;  eyes  suffused ;  (on 
enquiring  if  any  of  the  family  had  scarlatina,  I  found  his  son,  who  was 
lying  in  the  same  room,  just  recovering  from  it).  After  a  few  days, 
perspiration  appeared  over  the  surface  of  the  body,  the  fever  became 
less,  and  he  was  able  to  open  his  mouth  and  swallow  a  little.  On  first 
seeing  the  tonsils  and  velum,  I  found  them  coated  over  with  a  thick 
white  membrane,  which  extended  to  the  hard  palate,  and  could  be 
raised  off  easily  with  the  probe. 

"  Case  4. — ^P.  N.  has  been  complaining  of  headache  and  nausea 
since  yesterday,  feels  a  stiffness  in  his  throat,  and  fears  he  is  getting 
the  scarlatina,  as  three  of  his  children  are  only  recovering  from  it.  The 
throat  symptoms  increased  to  a  great  degree,  with  a  smart  fever  attend- 
ing them.     No  eruption  appeared,  and  he  was  well  in  eight  days. 

"  It  is  now  almost  generally  admitted  that  the  eruption  is  not  a 
necessary  symptom  of  scarlatina,  which  disease  may  occur  independently 
of  any  affection  of  the  skin.  In  this  case  the  throat  is  supposed  to  be 
invariably  affected,  and  the  disease  has  received  the  name  of  '  scarlatina 
faucium.'  But  it  may  be  a  matter  of  some  difficulty  to  diagnose  this 
scarlatinous  affection  of  the  throat  from  a  common  cynanche :  the  fact 
of  scarlatina  being  prevalent  in  the  neighbourhood,  and  the  probability 
of  the  infection  of  it  having  been  in  some  way  communicated,  must  in 
such  cases  be  taken  into  consideration.  If  it  be  found,  however,  that 
exposure  to  the  infection  of  one  disease  gives  rise  to  the  other,  and 
that  one  proves  a  preventive  of  the  other,  there  are  fair  reasons  for 
concluding,  that  it  is  the  same  disease,  in  the  one  case  affecting  the 
skin,  and  in  the  other  the  throat  only.'' 


SCARLATINA.  329 

In  Waterford,  Dr.  Elliott  announces,  that  for  several  years  scarlatina 
has  appeared  occasionally  in  an  epidemic  form,  sometimes  assuming 
great  malignity  during  the  congestive  stage,  whilst  its  peculiar  diag- 
nostic characters  were  as  yet  barely  discernible.  Dr.  Bewley,  of  Moate, 
mentions  that  it  has  not  prevailed  in  his  district  for  eleven  years,  and 
that  during  the  whole  of  this  period  he  had  not  a  fatal  case.  Dr. 
Thorpe,  of  Listowel,  has  seen  very  few  cases  of  the  disease,  and  has 
not  had  a  single  death.  Dr.  Gogerty,  of  Nobber,  (county  Meath),  has 
had  many  fatal  cases,  and  the  disease  has  been  very  prevalent.  In 
Pomeroy,  as  appears  from  the  statement  of  Dr.  Harvey,  the  disease  has 
been  rare  and  mild. 

Dr.  Connor,  of  Carlow,  writes  as  follows  : — "  I  delayed  answering 
your  circular  until  I  could  send  you  the  combined  opinion  of  some 
other  practitioners,  two  of  whom  agree  with  me  in  saying,  '  that  there 
is  annually  a  pretty  general  attack  of  scarlatina  in  this  district,  but 
nearly  confined  to  the  juvenile  and  infantine  portion  of  the  community, 
at  least  we  do  not  recollect  many  adults  affected  with  it,  and  only  one 
fatal  case  amongst  those,  and  that  was  the  case  of  a  lady  just  confined, 
and  whose  children  had  the  disease,  but  recovered.  As  to  the  mahg- 
nity  of  the  type,  we  can  say,  that  whilst  five  children  were  carried  off 
by  it  in  one  family,  others  in  the  same  house  had  it  slightly ;  and  although 
several  lost  two  or  more  children,  numbers  of  families  have  been  so 
slightly  afiected,  that  were  it  not  that  medical  men  recognised  the 
disease,  it  would  have  passed  away  without  any  notice,  requiring  in 
some  cases  only  the  little  patient  to  remain  one  day  or  two  in  bed. 
When  many  members  of  one  family  have  been  taken  away,  we  have 
had  reason  to  think  that  the  constitution  of  the  sufferers  had  more  to 
do  with  the  fatal  result  than  the  original  type  of  the  disease." 

Dr.  Long,  of  Arthurstown,  states,  that  during  the  years  1841-2, 
he  has  not  observed  a  single  case  of  scarlatina,  in  his  extensive  district  ; 
although  at  New  Ross,  which  is  but  ten  miles  distant,  the  disease  has 
prevailed  in  its  most  mahgnant  form,  and  been  attended  with  frightful 
mortahty.  But  that  in  the  summer  of  the  year  1839,  scarlatina  raged 
with  him  epidemically  for  some  months.  Its  general  character  was  at 
that  time  of  a  mild  type,  yet  in  some  cases  the  malignant  symptoms 
were  present.  He  had  then  occasion  to  remark,  that  in  the  same 
family  were  to  be  found  individuals  presenting  well  marked  cases  of 
every  form  of  the  disease,  from  the  simple  fever  with  bright  efflores- 
cence of  the  skin,  to  the  sloughing  tonsils  and  typhoid  type ;  and  that 
in  many  the  disease  appeared  to  attack  the  throat  alone,  presenting 
symptoms  tliat  would,  under  other  circumstances,  have  been  considered 
indicative  of  simple  cynanche  tonsillaris. 


330  CLINICAL  MEDICINE. 

Dr.  Eussell,  Surgeon  of  the  County  Tipperary  Infirmary,  reports 
that  in  the  year  1846,  scarlatina  was  very  prevalent  during  the  spring, 
and  assumed  a  most  fatal  form.  It  appeared  also  to  be  most  infectious, 
as  almost  every  individual,  except  those  who  had  the  disease  previously, 
who  came  near  the  infected  were  seized  with  it.  The  fever  was  of  a 
typhoid  character,  and  the  tliroat  appeared  as  if  affected  with  gangren- 
ous erysipelas.  The  treatment  that  appeared  most  useful  was  warm 
bathing  and  the  carbonate  of  ammonia  with  bark.  He  has  had  occa- 
sional cases  of  it  since,  but  not  at  all  of  the  same  fatal  form. 

In  Ballina,  Dr.  Whittaker  says,  the  disease  has  been  rare  and  mild. 
Dr.  Stewart,  of  Lifford,  states  that  two  epidemics  have  visited  that 
district  within  the  last  six  years ;  both  were  very  mild. .  Dr.  Croly,  of 
Mountmellick,  says,  "  that  scarlatina  has  at  intervals  prevailed  in  this 
locality  for  the  last  few  years.  Latterly  it  has  assumed  a  malignant  and 
fatal  type,  especially  among  children.  The  eruption  was  of  a  dark  hue 
with  early  tendency  to  sphacelated  ulceration  of  the  fauces  and  pharynx, 
cerebral  congestion  with  coma  and  convulsions." 

Prom  Dr.  O'Erien,  of  Ennis,  the  following  particulars  were  received : 
"  In  reply  to  your  circular,  relative  to  the  prevalence  of  scarlatina  in 
this  county,  I  have  not  many  observations  to  make,  as  it  is  only  within 
the  last  seven  or  eight  years  that  much  of  that  disease  has  been  seen 
here. 

"  My  father,  who  has  been  forty  years  in  practice  in  this  county,  told 
me  that  he  has  seldom  seen  the  disease,  and  that  it  never  prevailed  as 
an  epidemic  here.  About  seven  years  since  a  few  cases  appeared  here 
together,  and  it  did  not  re-appear  until  the  spring  of  the  year  1840, 
when  it  broke  out  in  a  large  school  in  this  town,  and  four  persons  died 
of  it.  I  was  in  attendance  on  them,  and  was  seized  with  it  myself, 
and  had  a  very  narrow  escape.  It  was  evidently  brought  to  the  school 
on  this  occasion  by  a  boy  who  had  just  come  from  the  King^s  County, 
and  who  showed  the  disease  in  a  day  or  two  after  his  arrival.  It  spread 
with  such  rapidity  tlirough  the  school,  that  (notwithstanding  the  great- 
est precaution)  the  establishment  had  to  be  broken  up  for  some  time. 
It  again  reappeared  about  Christmas  in  the  same  year,  to  a  shght  ex- 
tent ;  was  not  fatal,  and  has  not  been  seen  since." 

In  Boyle,  Dr.  Hall  says,  it  has  lately  been  prevalent  but  very  mild. 
Dr.  Taylor,  has  seen  very  few  cases  at  Terns,  all  of  which  were  mild. 
Dr.  Griffin,  of  Limerick,  writes  as  follows  : — ''  We  had  some  bad  cases 
of  scarlatina  in  Limerick  last  winter  (1841-2),  and  about  two  years 
ago,  but  they  were  few  in  comparison  to  the  mild  cases ;  and  at  any 
time  witliin  the  last  eight  or  ten  years  I  have  not  known  it  to  spread 
extensively  as  an  epidemic.     Those  who  died  of  the  complaint,  suffered 


SCAELATINA.  331 

chiefly  from  the  sloughing  of  the  throat ;  but  I  saw  one  young  girl  die 
last  year,  on  the  tliird  or  fourth  day,  apparently  from  the  intensity  of 
the  fever  and  great  prostration  of  strength." 

Prom  Dr.  Eoe,  of  the  Cavan  Infirmary,  I  received  the  following  full 
and  very  satisfactory  particulars.  His  letter  was  dated  29th  August, 
1842.  "Scarlatina,"  he  writes,  "has  been  more  than  usually  preva- 
lent daring  the  last  few  months.  I  have  only  seen  two  cases  of  it  in 
adults.  Amongst  children  I  cannot  say  that  those  cases  I  met  with 
were  unusually  severe  or  unmanageable.  The  soreness  and  swelHng  of 
the  throat,  with  ulceration,  were  also  very  prominent  and  painful  symp- 
toms in  several  cases  I  saw ;  the  sore  throat  appeared  almost  the  only 
spmptom,  and  the  cutaneous  affection  very  trifling  and  evanescent.  I 
cannot  say  that  the  type  of  the  disease  here,  as  far  as  I  met  with  it, 
was  of  a  mahgnant  character,  nor  did  it  put  on  that  congestive  inflam- 
matory form,  which  produces  such  an  awfully  fatal  disease.  I  have 
also  seen  two  or  three  examples  of  the  dropsical,  or  anasarcous  symp- 
toms which  sometimes  succeed ;  and  in  one  very  fine  healthy  child, 
wliich  I  had  an  opportunity  of  seeing  the  evening  before  its  death,  and 
of  making  a  jpod  mortem  examination,  I  found  the  entire  cellular 
substance  of  the  body  pervaded  with  the  dropsical  effusion,  and  a  very- 
large  quantity,  amounting,  I  think,  to  nearly  a  quart,  effused  into  the 
thorax.  Erom  the  great  dyspnea,  and  very  unequal  action  of  the  heart, 
I  presumed  there  must  be  structural  disease  of  the  heart — which  was 
not  the  case — and  all  the  viscera,  both  of  the  thorax  and  abdomen, 
appeared  perfectly  sound,  so  that  the  dropsy  was  entirely  the  result  or 
the  consequence  of  the  original  disease  three  weeks  before,  and  from 
which  the  child  appeared  to  have  perfectly  recovered. 

"  Scarlatina,  mixed  up  with  small  pox,  has  appeared  also  in  our  poor 
house,  but  not  of  a  very  fatal  or  malignant  character ;  and  I  find  from 
the  physician  of  the  poor  house,  that  the  scarlatina  was  rather  of  a 
low  type,  and  required  cordials,  as  wine,  &c.,  and  that  bleeding  was 
had  recourse  to  only  in  a  few  cases.  Some  years  ago,  when  it  appeared 
in  an  epidemic,  and  very  severe  form,  I  had  an  opportunity  of  seeing 
much  more  of  it,  and  then  I  found  the  most  beneficial  effects  from 
fuU  and  early  bleeding ;  and  in  two  remarkable  instances,  one  an  adult 
lady  and  the  other  a  fine  healthy  girl,  I  think  it  put  an  end  to  the  dis- 
ease, and  prevented  the  congestive  stage  from  coming  on." 

It  is  unnecessary  to  give  the  particulars  of  the  many  letters  I  have 
received  on  this  subject ;  but  from  all  may  be  collected  the  facts,  that 
scarlatina  has,  generally  speaking,  prevailed  to  an  unusual  extent  in 
Ireland,  from  1836  to  1844 ;  that  it  has,  in  many  instances,  been  sin- 
gularly rare  in  districts  immediately  adjoining  others  in  which  it  has 


332  CLINICAL   MEDICINE. 

been  equally  prevalent — that  there  is  no  geological  or  physical  difierence 
in  many  of  the  localities  alluded  to,  which  can  in  any  way  account  for 
these  anomaHes — and  that  we  are  equally  at  a  loss  to  explain  its  mild- 
ness in  some  districts  in  which  it  has  extensively  prevailed,  and  its 
malignity  in  others. 

Even  in  tliis  city,  during  the  period  of  its  greatest  virulence,  whole 
families  have  been  attacked  with  the  mildest  forms  of  the  disease  I  have 
ever  seen ;  and  I  have  been  assured  by  many  of  the  physicians  connected 
with  our  dispensaries,  that  they  have  for  a  certain  period  met  with  several 
cases,  all  extremely  mild,  and  suddenly  the  character  of  the  disease  has 
changed,  and  the  cases  then  coming  before  them  were  as  remarkable  for 
their  malignancy,  and  undue  proportion  of  mortality.  This  was  seen  in 
a  remarkable  degree  in  the  practice  of  Dr.  Osbrey,  Physician  to  St. 
Mary's  Dispensary,  whose  very  important  communication  I  shall  read 
for  you. 

"  The  number  of  cases  of  scarlet  fever,"  says  he,  "  which  were  under 
my  care  from  the  close  of  the  year  1 840,  the  period  at  which  that  epi- 
demic first  appeared  in  my  dispensary  district,  until  its  decline  at  the 
commencement  of  the  present  year,  amounted  to  somewhat  above  two 
hundred. 

"  When  it  first  appeared  the  epidemic  was  of  so  mild  a  character  that 
I  treated  above  forty  cases  without  the  occurrence  of  a  single  fatal  one ; 
merely  attending  to  the  state  of  the  bowels  and  secretions  was  suJSicient 
to  effect  a  cure.  It  soon,  however,  assumed  a  more  formidable  character. 
The  cases  which  mostly  proved  fatal  were  those  affected  with  diffuse  in- 
flammation of  the  neck ;  they  were  generally  children  under  four  years 
of  age.  As  it  may  be  interesting  I  shall  describe  to  the  best  of  my 
recollection  the  progress  of  that  affection,  together  mth  the  treatment 
which  I  found  to  be  most  successful, 

^*  Those  cases  of  scarlatina  in  which  this  form  of  inflammation  pre- 
sented itself,  I  was  usually  not  requested  to  attend  until  some  time  after 
its  commencement,  which  generally  took  place  at  the  decHne  of  the 
eruption  on  the  third  or  fourth  day.  The  attending,  or  I  may  say 
secondary  fever,  was  principally  marked  by  the  occurrence  of  cerebral 
and  nervous  symptoms,  the  child  either  lay  in  a  comatose  state,  or  was 
excessively  irritable  and  restless,  and  constantly  whiuing.  In  those  who 
were  a  few  years  older,  a  peculiar  wildness  of  manner  was  occasionally 
observed,  and  if  this  were  absent,  the  expression  of  the  countenance  was 
stupid  and  vacant.  A  common  remark  of  their  mothers  was,  '  that  they 
did  not  consider  them  in  their  right  mind.'  The  children  were  affected 
with  tremors  of  the  extremities ;  the  pulse  was  generally  quick,  and  the 
tongue  furred,  but  neither  invariably  so. 


SCARLATINA.  833 

"  The  progress  of  the  inflammation  was  very  insidious,  in  most  cases 
(commencing  as  an  indurated  swelling  behind  the  angle  of  the  jaw  on  one 
side,  which  was  at  first  very  indolent,  without  any  discoloration  of  the 
integuments,  but  as  the  affection  advanced  the  swelling  increased  much 
more  rapidly,  often  extending  to  the  opposite  side  :  the  integuments  then 
assumed  a  dusky  red  appearance,  and  became  very  tender  to  the  touch ; 
there  was  much  oedema,  so  that  the  part  readily  pitted  when  pressed  by 
the  finger,  and  there  was  an  obscure  sense  of  fluctuation  communicated 
to  the  touch.  In  the  advanced  stage  of  the  complaint,  sensibility,  which 
was  previously  great,  diminished  to  such  a  degree  that  the  child  did  not 
seem  to  suffer  much  pain  if  incisions  were  made  into  the  swelling.  When 
the  patient  survived  till  about  the  tenth  day  from  the  commencement  of 
the  afi'ection,  sloughs  frequently  formed,  commencing  in  dark  purple 
specks  over  the  surface  of  the  swelling,  the  sloughing  rapidly  spread, 
diarrhoea  then  set  in ;  the  abdomen  became  tympanitic  ;  spots  of  purpura 
at  times  appearing  over  the  surface  of  the  hodj,  with  the  occurrence  of 
passive  hemorrhage  from  the  mouth  and  bowels.  The  child  either  died 
comatose  or  exhausted  by  diarrhoea,  in  case  dissolution  was  not  quickened 
by  the  supervention  of  sudden  hemorrhage  from  some  of  the  large  vessels 
of  the  neck  giving  way  in  sloughing.  An  attack  of  convulsions  some- 
times preceded  death,  the  period  of  which,  unless  when  precipitated  by 
exhausting  treatment,  to  which  it  had  been  submitted  previous  to  my 
seeing  the  child,  varied  from  the  seventh  to  the  twenty-eight  day ;  the 
medium  time  being  about  the  twelfth  day  from  the  commencement  of 
the  inflammation. 

"  In  those  cases  which  fell  under  my  observation  I  did  not  notice  any 
thing  differing  from  the  common,  either  in  the  appearance  or  duration  of 
the  eruption,  except  that  it  was  occasionally  somewhat  more  faint  than 
usual,  and  that  the  desquamation  of  the  cuticle  did  not  take  place  after 
its  disappearance.  Though  what  I  have  just  described  was  the  usual 
progress  of  inflammation  when  it  ran  a  fatal  course,  vet  sometimes  it 
commenced  earlier,  on  the  first  or  second  day  of  the  eruption,  the  fever 
being  of  a  more  inflammatory  type,  the  skin  being  hot,  pulse  strong, 
tongue  furred,  and  much  thirst  being  present. 

"  It  is  well  known  that  this  disposition  to  slough  in  scarlatina  is  not 
confined  to  diffuse  inflammation  of  the  neck,  and  that  an  inflammation 
of  a  similar  character  may  attack  other  parts  of  the  body — this  was  well 
exemplified  in  two  cases  which  were  under  my  care — one  that  of  a  boy, 
aged  six  years,  in  whom  scarlet  fever  immediately  succeeded  an  attack  of 
hooping  cough,  for  the  relief  of  which  I  had  found  it  necessary  to  apply 
a  blister  to  the  chest,  the  other  that  of  a  fine  child,  his  sister,  aged  four, 
who  had  received  a  slight  scald  in  the  ham  of  the  left  leg;  such  portions 


334  CLINICAL   MEDICINE. 

of  the  vesicated  surfaces  which  had  not  as  yet  healed^  were  attacked  by 
the  inflammation^  they  were  rapidly  covered  with  ash-coloured  sloughs, 
and  the  sloughing  extended  by  livid  margins.  The  boy  exhausted  by 
the  previous  attack  of  hooping  cough,  which  had  been  unusually  severe, 
died ;  the  little  girl  recovered.  The  treatment,  which  was  the  same  in 
both,  consisted,  locally,  in  the  ulcers  being  kept  constantly  covered  with 
fermenting  poultices,  and  in  the  margins  being  occasionally  touched  with 
strong  muriatic  acid.  The  cautious  exhibition  of  mild  tonics,  and  of 
stimulants,  both  diffusible  and  permanent,  carbonate  of  ammonia,  of 
course,  being  used  amongst  the  former,  constituted  the  general  treatment. 
Another  case,  which  I  considered  very  remarkable,  fell  under  my  obser- 
vation, in  which  simultaneously  with  the  gangrene  of  the  necJc,  sloughs 
formed  on  both  corneas^  which  rapidly  extended,  involving  all  the  other 
textures  of  the  eyes.  This  case  my  friend.  Dr.  Battersby,  saw  with  me. 
The  destruction  of  the  eyes  took  place  two  days  before  dissolution.  In 
each  of  these  three  cases  the  appearance  of  the  part,  when  destroyed, 
closely  resembled  that  of  hospital  gangrene.  I  did  not  notice  any  depots 
of  purulent  matter  in  the  joints,  or  any  other  parts  of  the  body. 

"  Having  now  described  the  more  formidable  characters  of  the  inflam- 
mation, I  shall  state  the  treatment  which  I  found  most  eflicacious  in 
arresting  its  progress,  and  in  bringing  about  the  more  favourable  termi- 
nations of  resolution  and  abscess,  and  shall  also  take  a  short  review  of 
other  modes  of  treatment  that  are  occasionally  resorted  to.  Mine  simply 
consisted  in  the  constant  application  of  common  oatmeal  or  linseed  poul- 
tices, supporting  the  child's  strength  by  nourishing  diet,  and  in  the 
cautious  exhibition  of  permanent  and  diffusible  stimulants,  carbonate  of 
ammonia,  as  I  have  already  said,  being  included  in  the  latter.  The 
practitioner  should  not  I  think  swerve  from  this  line  of  practice,  though 
he  may  sometimes  be  urged  by  the  parents  alarmed  at  the  progress  of 
the  inflammation,  to  treat  the  child  more  actively,  particularly  with  res- 
pect to  the  local  applications.  When  an  abscess  forms,  the  swelling 
previously  diffused,  becomes  more  prominent,  soft,  and  fluctuating,  there 
is  no  pitting  on  pressure  with  the  finger,  and  the  surface  is  usually  of  a 
rose  red  colour.  Incisions  may  be  then  made  to  give  exit  to  the  matters. 
The  symptoms  of  general  disturbance,  such  as  coma,  convulsions,  and 
such  others  as  have  been  described  in  such  cases  disappear,  tremors  of 
the  extremities  alone  remaining,  and  the  child  gradually  recovers  from 
the  extreme  debility  frOm  which  it  had  hitherto  suffered.  I  have  said 
that  stimulants  should  be  given  with  much  caution,  for  when  used 
at  all  freely  they  are  ahnost  sure  to  induce  convulsions,  to  which 
there  is  a  great  tendency  throughout  the  progress  of  the  complaint. 
After  the  formation  of  abscess,  however,  they  may  be  exhibited  with 


SCARLATINA.  8:35 

greater  boldness.  In  cases  were  tlu  re  is  much  restlessness  and  irrita- 
bility, or  when  diarrhoea  has  set  in,  which  usually  does  not  take  place 
until  the  sloughing  has  commenced,  I  have  given  opiates,  either  in  the 
form  of  Dover^s  powder,  or  the  pulvis  cretse  compositus  cum  opio,  the 
doses  being  carefully  graduated  according  to  the  age  of  the  child.  When 
the  cases  became  complicated  with  purpura  and  passive  hemorrhage,  it 
is  almost  unnecessary  for  me  to  say,  that  I  gave  the  mineral  acids. 

"  I  have  ordered  chloride  of  soda  both  internally  and  as  a  lotion.  Its 
internal  exhibition  did  not  appear  to  be  productive  of  any  benefit,  but 
as  a  lotion  and  gargle  it  was  highly  useful  in  destroying  fetor.  When 
I  apprehended  internal  sloughing  I  occasionally  touched  the  throat  with 
muriatic  acid  lotions  by  means  of  a  cameFs-hair  pencil  or  a  piece  of  a 
sponge. 

"  Having  had  frequent  opportunities  of  seeing  the  effects  produced  by 
the  use  of  mercury,  and  also  by  local  bleeding  in  the  practice  of  others, 
I  carefully  avoided  having  recourse  to  such  methods  of  treatment  my- 
self; the  former,  with  rare  exceptions,  inducing  purpura,  passive  he- 
morrhages, and  sloughing,  the  accession  of  which  is  so  much  to  be 
dreaded,  and  which  are  so  liable  to  supervene  of  themselves.  The  latter  pre- 
cipitating dissolution  by  increasing  the  disposition  to  coma  and  collapse. 

"  I  have  in  some  cases  made  incisions  into  the  swellings  extending 
beneath  the  fascia  of  the  neck,  but  I  do  not  consider  it  good  practice  in 
the  case  of  young  children,  however  useful  it  may  be  in  that  of  adults, 
and  of  grown  children,  for  the  following  reasons  :  when  made  in  the 
early  stage  of  the  inflammation  they  have  a  tendency  to  prevent  the  oc- 
currence of  either  of  those  most  favourable  results — resolution  or  ab- 
scess; and  when  made  in  the  advanced  stages,  unless  when  abscess  or 
diffuse  suppuration  takes  place,  they  are  of  no  use,  they  do  not  appear 
to  check  the  sloughing  of  the  integuments.  The  parents  moreover  to 
whose  feelings  such  practice  is  generally  repugnant,  are  very  apt  to  at- 
tribute whatever  ill  afterwards  befalls  their  child  to  these  incisions  having 
been  made,  a  consideration  which  I  think  should  weigh  with  us  in  de- 
termining against  the  practice,  when  no  good  is  likely  to  arise  from  it. 
In  case,  however,  abscess  or  diffuse  suppuration  of  the  cellular  mem- 
brane occur  we  should  not  hesitate  to  make  free  openings.  Diffuse  sup- 
puration of  the  cellular  membrane,  a  result  which  I  have  only  now  al- 
luded to,  is  almost  as  formidable,  when  the  children  are  very  young,  as 
gangrene,  inasmuch  as  they  are  scarcely  ever  able  to  bear  up  against  the 
extensive  suppuration,  and  consequently  die  of  hectic. 

"  Blisters  and  mustard  cataplasms,  merely  applied  as  rubefacients,  did 
not  appear  to  me  to  be  injurious,  but  I  did  not  place  much  confidence  in 
them. 


336  ^  CLINICAL   MEDICINE. 

"  It  is  obvious  from  what  has  been  already  observed,  that  we  should 
be  most  cautious  in  making  a  prognosis  when  we  meet  this  form  of  in- 
flammation, as  it  often,  when  most  mild  at  its  commencement,  subse- 
quently runs  a  most  fatal  course,  and  when  apparently  of  a  most  formid- 
able character,  terminates  kindly.  I  have  known  many  a  practitioner, 
from  mistaking  its  nature,  supposing  it  to  be  nothing  more  than  com- 
mon scrofulous  inflammation,  to  augur  favourably  as  to  its  termination, 
when  its  subsequent  course  showed  how  very  erroneous  such  an  opinion 
was.  The  constitutional  symptoms,  however,  even  though  we  have  no 
very  clear  evidence  of  the  child  having  had  scarlet  fever,  will,  when  care- 
fully attended  to,  always  enable  us  to  form  a  correct  diagnosis  of  the 
disease.  Perhaps  it  is  from  not  recognising  this  disease,  which  is  one  of 
the  most  formidable  consequences  of  scarlet  fever,  that  such  discrepan- 
cies have  occurred  in  the  returns  made  by  practitioners  of  the  relative 
mortality  of  scarlatina  in  their  practice.  The  children  are  frequently 
not  brought  to  them  till  all  traces  of  the  eruption  have  disappeared,  and 
in  some  cases,  where  it  has  been  so  faint  as  to  have  escaped  the  observa- 
tion of  the  parents,  or  even  that  of  the  physician.  In  such  cases  it  is 
easy  to  conceive  that  it  might  be  mistaken  for  a  disease  sui  generis, 
and  that  the  previous  existence  of  scarlatina  might  be  entirely  over- 
looked. 

"  When  sloughing  of  the  integument  has  commenced,  the  chances  of 
the  child^'s  recovery  are  greatly  diminished,  and  when  it  is  under  a  year 
old,  it  is,  I  think,  almost  hopeless.  To  have  an  opportunity  of  observing 
the  sloughing  stage,  it  is  requisite  that  the  child  should  survive  some 
time.  When  death  is  precipitated  by  injudicious  treatment,  or  if  the 
child  does  not  undergo  any,  dissolution  occurs  so  early  from  the  second- 
ary fever,  that  no  further  local  appearances  than  the  more  diffused 
swelling  will  be  observed.  I  should  here  mention,  that  in  the  worst 
cases,  there  is  no  attempt  at  suppuration,  and  the  part,  when  cut  into, 
resembles  somewhat  the  cut  surface  of  a  rotten  apple. 

"  Even  when  resolution  or  abscess  occurs,  we  must  not  be  too  hasty 
in  giving  a  favourable  prognosis ;  for  there  is  occasionally  much  subse- 
quent debility,  which  may  lead  to  a  fatal  result. 

"  I  have  observed  instances  of  this  form  of  inflammation  which  suc- 
ceeded other  exanthemata.  The  following  case  is,  I  think,  an  interest- 
ing example.  It  is  that  of  a  child  aged  two  years,  that  had  an  attack 
of  the  natural  small-pox  ten  days  previous  to  my  seeing  it,  and  had  been 
treated  by  another  physician,  who,  on  the  occurrence  of  the  inflamma- 
mation  of  the  neck,  (I  understood  from  its  mother),  despaired  of  its  re- 
covery j  and  indeed,  when  I  myself  visited  it  I  had  no  better  hopes.  It 
was  then  lying  in  a  state  of  coma,  with  its  head  quite  motionless  and 


SCARLATINA.  337 

thrown  back,  a  large  diffused  swelling  being  behind  the  angle  of  each 
jaw  and  extending  down  the  neck.  The  pulse  was  remarkably  quick 
and  weak,  the  tongue  furred,  abdomen  tympanitic.  On  the  child  being 
submitted  to  the  mode  of  treatment  which  I  have  described,  it  recovered 
from  the  state  of  coma  it  was  in,  and  two  very  large  abscesses  formed 
in  the  situation  of  the  swellings,  which  I  subsequently  opened.  The 
tympanitic  state  of  the  abdomen  was  relieved  by  injections  of  castor-oil 
and  turpentine.  When  the  sensibility  and  intelligence  of  the  child  re- 
turned, it  was  attacked  with  convulsions,  consisting  in  constant  motion 
of  the  extremities  and  twitchings  of  the  face,  which  continued  for  two 
days.  These  convulsions  I  ascribed  to  debility,  and  treated  as  such. 
In  this  case  purulent  depots  formed  over  the  back  of  the  hand  and  one 
foot ;  also  a  large  one  over  the  scapula.  The  two  former  have  been  ab- 
sorbed; but  as  the  one  over  the  scapula  still  continues,  and  as  there  is 
no  chance  of  its  absorption,  the  recovery  of  the  child  is  still  doubtful. 
A  few  spots  of  purpura  appeared  in  different  parts  of  its  body,  and  it 
has  been  frequently  attacked  with  diarrhoea.  Its  mother  states,  that  it 
was  a  strong  child  before  the  attack  of  small-pox.  It  is,  however,  ap- 
parently of  scrofulous  habit,  and  had  once  suffered  from  rickets," 


VOL.  I.  22 


338 


LECTURE  XXIY. 


SCARLATINA ^ABSENCE   OF   ERUPTION — DROPSY  AFTER. 

Any  one  who  has  studied  our  old  authors  with  care,  will  perceive  the 
identity  that  exists  between  some  forms  of  our  malignant  scarlatina  and 
the  epidemics  described  by  the  name  of  the  "  Ulcerous  Sore  Throat/'"^ 
and  the  ^^  Putrid  Sore  Throat  "-^  But  in  these  epidemics^  the  principal 
and  fatal  symptoms  were  inflammation  and  sloughing  of  the  throat, 
ulceration  of  the  schneiderian  membrane,  attended  with  profuse  ichorous 
discharges,  &c.  The  eruption  was  either  disregarded,  or  only  men- 
tioned as  a  curious  phenomenon,  and  death  was  produced  by  the  "  sore 
throat."  But  as  w^as  before  observed,  many  of  our  cases  died  without 
a  single  lesion  that  we  could  detect — thei/  were  poisoned  hy  the  virus  of 
the  sca'rlatina. 

I  shall  now  bring  before  you  the  particulars  of  a  few^  fatal  cases  that 
were  lately  under  my  care,  from  which  you  will  be  enabled  to  form  a 
better  idea  of  the  malady.  The  following  notes  were  taken  by  Dr. 
Henry  Kennedy,  by  whom  the  patient  was  first  seen — 

Case  1. — "  I  first  saw  J.  K ,  aged  14,  onEriday  evening,  March 

22,  ]  842.  He  had  been  at  school  the  previous  day,  but  had  come 
home  complaining  of  not  being  well.  His  mother  had  given  him  an 
emetic  of  ipecacuanha,  which  not  only  vomited  but  appeared  also  to 
have  purged  him.  When  visited  about  twenty-seven  hours  from  the 
beginning  of  his  illness,  the  purging  had  ceased,  but  the  vomiting  con- 
tinued incessantly.  He  was  throwing  up  quantities  of  dark  greenish 
bile,  and  this  occurred  whether  he  took  any  drink  or  not.  The  tliirst 
was  insatiable,  and  the  desire  was  for  what  was  cold ;  the  fever  ran  very 
high,  the  skin  hot,  pulse  140,  and  when  left  to  himself  he  was  inclined 
to  rave ;  he  referred  his  distress  to  the  stomach,  and  said  he  believed 

*  Huxham  on  Fevers,  page  26G.     London.    1772. 

+  Fothergill's  Works,  Vol.  i.  page  341.    London.    1783. 


SCAULATINA.  339 

his  throat  was  sore ;  on  looking  into  the  mouth  the  internal  fauces 
appeared  inflamed^  and  the  tongue  was  densely  loaded,  but  there  was 
nothing  of  that  specific  nature  which  would  lead  one  to  pronounce  on 
the  nature  of  the  disease.  At  this  time  I  looked  very  particularly  to  the 
state  of  the  skin,  but  no  eruption  was  visible.  His  position  in  bed  was 
changed  every  moment,  as  he  said  for  the  purpose  of  giving  himself 
relief.  I  had  intended  putting  a  few  leeches  over  the  stomach,  but  at 
the  patient's  own  urgent  request  was  induced  to  bleed  him  from  the 
arm  to  about  seven  ounces.  A  sinapism  was  applied  to  the  epigas- 
trium, a  mouthful  of  cold  water  given  frequently,  and  the  extremities 
vsponged  with  vinegar  and  water.  On  the  following  morning  (Satur- 
day) all  the  symptoms  had  increased  in  severity,  the  treatment  of  the 
night  before  had  only  temporary  effect,  in  fact  for  about  four  hours, 
after  which  all  the  symptoms  had  reappeared.  In  addition  the  body 
was  now  covered  with  an  eruption  which  could  not  be  distinguished 
from  the  maculae  of  bad  typhus  fever ;  it  was  best  marked,  however,  on 
the  chest  and  back ;  it  was  quite  distinct  on  the  face.  The  raving  was 
now  of  a  more  decided  character,  and  it  was  more  difficult  to  make  him 
give  a  direct  answer.  At  this  period  Dr.  Graves  visited  the  patient, 
and  recommended  internal  stimulants  with  bhsters  to  the  surface.  It 
is  enough  to  add,  that  all  treatment  appeared  to  be  quite  useless,  and 
from  this  time  till  the  period  of  the  patient's  death,  every  symptom  went 
on  increasing,  the  raving  becoming  every  hour  more  violent  in  its  cha- 
racter, and  the  pulse  rising  to  170  and  even  180.  One  or  two  points 
are,  however,  worthy  of  notice.  During  the  last  day  of  life  the  bowels 
were  once  afi^ected,  the  discharge  quite  natural,  and  from  this  moment 
all  vomiting  ceased.  During  this  day  also  a  second  crop  of  eruption 
made  its  appearance,  it  was  perfectly  distinct  from  the  first,  being  of  a 
reddish  colour,  and  the  spots  much  more  circumscribed.  I  have  often 
had  occasion  to  meet  with  the  same  since ;  it  was  now  that  the  tongue 
put  on  its  characteristic  appearance.  That  the  nervous  system  was  pro- 
foundly engaged  there  was  but  two  much  evidence  of,  for  though  no 
convulsion  came  on  I  observed  strabismus,  and  the  mouth  was  dis- 
tinctly drawn  to  one  side.  There  were  also  very  violent  fits  of  shud- 
dering almost  amounting  to  rigor ;  the  eyes  were  not  at  all  injected. 
The  entire  duration  of  this  patient's  illness  was  about  sixty-eight  hours." 

In  the  patient  whose  case  has  been  detailed  we  have  a  remarkable 
example  of  scarlatina  terminating  rapidly  in  death,  without  the  slough- 
ing of  the  throat,  which  usually  caused  death  in  the  epidemics  nan'ated 
by  Huxham  and  Pothergill. 

Case  2. — Miss  H ,  a  strong  healthy  lad}^,  set.  28,  was  attended 

at  the  commencement  of  her  illness  by  Mr.  Nicholls ;  when  I  saw  her. 


340  CLINICAL    MEDICINE. 

there  were  intense  redness  of  the  throat,  great  dysphagia,  and  pain  in 
swallowing.  These  symptoms  induced  me  to  bleed  once  freely ;  the 
blood  was  buffed  and  cupped  to  an  extreme  degree.  After  the  disease 
had  lasted  for  about  thirty-six  hours,  an  eruption  of  a  vivid  bright  colour 
appeared.  She  obtained  no  relief  from  the  bleeding,  the  pulse  became 
quicker,  debihty  increased,  and  she  died  with  symptoms  of  poisoning  in 
less  than  two  days. 

The  occurrence  of  arthritis  as  a  complication  of  scarlatina,  we  have 
frequently  witnessed  in  the  Meath  Hospital.  In  a  man  named  Pierce, 
we  had  the  greatest  difficulty  to  save  both  wrist  joints  from  ulceration. 
And  in  another  case,  the  motion  of  the  elbow  joint  was  almost  lost  from 
the  effects  of  inflammation. 

I  have  noticed  that  when  any  of  the  viscera  became  engaged  during 
the  progress  of  this  disease,  that  there  is  the  greatest  difficulty  in  sub- 
duing the  local  affection,  and  that  it  runs  its  course  with  great  rapidity ; 
this  was  unfortunately  too  ^ell  illustrated  by  the  case  of  P.  E.  attended 
by  Surgeon  Smyly,  of  Merrion- square,  and  myself.  The  notes  of  the 
case  were  taken  by  Mr.  Smyly — 

Case  3.— Miss  P.  B ,  aged  20 ;  of  a  full  habit  of  body,  in  De- 
cember, 1841,  was  attacked  with  a  very  severe  form  of  scarlatina.  The 
eruption  appeared  on  the  20th,  and  was  very  intense  in  its  character ; 
in  the  progress  of  the  complaint  her  head  became  much  engaged  re- 
quiring the  apphcation  of  leeches ;  her  throat  also  was  very  bad,  to 
relieve  which  leeches  were  again  applied.  Considerable  prostration  of 
strength  accompanied  the  affection  from  the  commencement.  On  the 
30th  she  was  so  far  recovered  that  I  took  my  leave. 

It  may  be  worthy  of  remark  that  her  sister,  who  was  first  affected 
with  the  disease,  had  it  so  mildly  that  the  nature  of  the  affection  was 
not  discovered,  nor  did  she  require  medical  aid. 

January  9,  1842,  I  was  again  called  to  see  Miss  B ,  she  then 

complained  of  severe  pain  in  her  left  side,  which  she  first  felt  on  going 
to  bed,  which  became  so  violent  during  the  night  as  to  banish  sleep. 
She  had  been  till  then  going  on  as  well  as  possible,  recovering  her 
strength  daily  and  was  in  excellent  spirits.  On  the  8th,  she  eat  heartily 
of  beef-steaks  for  dinner,  and  drank  some  wine.  I  saw  her  sixteen 
hours  after  the  commencement  of  the  pain,  when  I  found  all  the  lower 
part  of  the  left  lung  densely  hepatized. 

The  treatment  consisted  in  repeated  cupping,  attended  each  time  with 
much  relief,  the  exhibition  of  mercury  so  as  to  affect  the  mouth,  anti- 
monials ;  by  all  which  means  the  acute  symptoms  disappeared,  but  no 
improvement  took  place  in  the  condition  of  the  lung.  Her  strength 
began  to  fail,  and  she  died  on  the  morning  of  the  9th  of  January,  1842. 


SCARLATINA.  341 

111  this  case  the  most  remarkable  feature  was  the  rapidity  with  which 
the  lung  was  solidified,  and  the  obstinate  manner  in  which  it  refused  to 
yield  to  treatment. 

The  following  case  was  also  attended  by  Mr.  Smyly  and  me;  it 
presents  an  unusual  sequela  of  scarlatina,  namely,  aphthous  ulceration 
of  the  anus,  which,  though  not  sufficiently  pointed  out  in  the  late 
works  on  practice  of  medicine,  was  recognised  and  described  by  Huxliam, 
and  I  introduce  our  case  with  Huxham's  description,  to  show  more 
clearly  the  identity  of  the  two  epidemics. 

After  alluding  to  the  profuse  discharge  that  took  place  from  ulcerated 
surfaces  in  the  mouth  and  nostrils,  he  says — "  A  sudden  stoppage  of 
this  rheum  from  the  mouth  and  nostrils  actually  choaked  several  chil- 
dren ;  and  some  swallowed  such  quantities  of  it,  as  occasioned  excoria- 
tions of  the  intestines,  violent  gripings,  dysentery,  &c.  nay  even  excoria- 
tions of  the  anus  and  buttocks."^ 

Case  4. — Master  James  F.,  aged  twelve,  was  affected  with  a  very  se- 
vere form  of  scarlatina  in  July  1841.  The  eruption  began  to  appear 
the  second  day  of  his  illness,  and  became  very  intense  in  its  character, 
the  whole  surface  of  the  skin  being  almost  of  a  uniform  redness.  The 
accompanying  fever  ran  very  high,  demanding  venesection  to  reduce  it. 
The  throat  presented  the  usual  appearance ;  but  in  this  case,  the  in- 
flammation extended  into  the  mouth,  and  we  suspected,  throughout  the 
intestinal  canal,  indicated  by  the  great  irritability  of  the  stomach  and 
bowels,  and  the  circumstance  of  the  anus  presenting  the  same  aphthous 
appearance  that  the  mouth  did.  The  inflammation  also  extended  into 
the  left  ear  and  caused  the  destruction  of  the  membrana  tympani.  In 
less  than  a  month^s  time  this  young  gentleman  was  so  far  recovered  as 
to  return  to  England,  and  has  since  enjoyed  good  health. 

In  the  writings  of  Huxham  and  Fothergill,  you  wiU  also  find 
frequent  allusions  to  cases  where  death  was  produced  by  uncontrollable 
epistaxis,  during  the  epidemic  of  "  sore  throat"  described  by  these  au* 
thors.  Thus  Fothergill  after  speaking  of  the  usual  mode  of  death  in 
these  cases  says^  "  Though  this  was  the  common  progress  of  the  disease 
where  it  terminated  unhappily,  yet  it  often  varied  from  this  type,  and 
was  attended  with  very  different  symptoms.  Some  had  an  extreme 
difficulty  of  breathing  almost  from  the  first ;  some  had  a  violent  cough ; 
some  were  comatous ;  others  had  a  delirium ;  some  died  in  a  lethargic 
stupor ;  others  hied  to  death  at  the  nose.^f  The  following  is  an  example 
of  this  form  of  the  disease. 

Case  5. — I  was  called  to  see  the  Eev.  Mr.   C,   aged  25,   of  regular 

*  Huxham  on  Fevers,  p.  200.    London.    1772. 

t  Fothergill's  Workis,  Vol.  i.  p  363.    London.    1/83, 


342  CLINICAL   MEDICINE. 

temperate  habits  and  healthy  constitution.  He  was  then  labouring  un- 
der severe  fever  with  sore  throat.  On  examining  the  fauces  I  found  the 
tonsils  extensively  ulcerated.  These  were  touched  with  nitrate  of  sil- 
ver^ and  the  next  day  they  appeared  much  improved.  On  the  third  day 
of  his  illness  an  eruption  appeared,  neither  too  red  nor  too  pale,  in 
short  as  favourable  as  could  be  wished  for,  and  perfectly  normal  as  to 
its  duration.  During  all  this  time  the  heat  was  intense ;  and  on  the 
third  day  of  the  eruption,  the  cold  affusion  was  employed,  and  was  fol- 
lowed by  marked  relief :  but  the  pulse  still  remained  sharp  and  quick, 
never  falling  below  96.  In  this  state  he  continued  till  the  seventh  day 
of  liis  illness,  when  epistaxis  occurred,  (to  this  he  had  been  subject  for 
a  long  time),  and  was  followed  by  considerable  relief  of  his  head.  The 
epistaxis  was  not  excessive,  and  from  the  fact  of  its  being  habitual,  ex- 
cited but  little  alarm.  About  the  thirteenth  day  the  fever  had  almost 
gone ;  his  sleep  was  good,  and  his  tongue  moist  and  clean.  At  this 
time  a  small  tumour,  situated  at  the  angle  of  the  left  jaw,  and  which 
had  been  there  from  the  beginning,  was  observed  to  enlarge.  The 
next  day  it  had  spread  considerably,  was  very  red  and  painful.  The 
fever  increased,  the  tongue  became  dry,  and  his  sleep  was  disturbed. 
On  the  sixteenth  the  tumour  was  examined  and  opened  by  Mr. 
Cusack. 

A  large  quantity  of  good  healthy  pus  escaped,  and  the  patient  ex- 
perienced great  ease.  On  the  eighteenth  day  a  deeper  incision  w^as 
made  by  Mr.  CuSack,  and  again  a  large  quantity  of  good  pus  escaped ; 
but  on  this  occasion  no  relief  followed.  On  the  next  day  the  consti- 
tutional symptoms  were  much  more  severe ;  the  epistaxis  returned,  and 
the  tongue  was  now  dry,  black,  and  bleeding.  There  was  no  raving, 
nor  was  he  at  any  time  during  the  illness  in  the  least  dehrious. 

Notwithstanding  that  the  nares  were  plugged,  and  every  measure 
which  Mr.  Casack  and  I  could  think  of  employed,  the  epistaxis  con- 
tinued, the  bleeding  from  the  tongue  could  not  be  arrested,  the  tumour 
in  the  neck  became  gangrenous,  and  on  the  twentieth  day  of  his  illness 
death  terminated  his  sufferings.  • 

The  next  very  interesting  case  was  communicated  to  me  by  Professor 
Porter,  and  as  it  illustrates  another  sequela  of  scarlatina,  I  shall  read  it 
for  you.  There  can  be  no  doubt  that  the  hemorrhage  originated  in  the 
way  pointed  out  by  Dr.  Porter,  and  it  shows  in  a  convincing  manner 
the  assistance  in  diagnosis  which  we  derive  from  an  accurate  knowledge 
of  anatomy.  It  will  also  be  recollected,  that  this  case  differs  in  the 
manner  in  which  the  bleeding  occurred  from  that  mentioned  in  a  preceding 
lecture  by  Dr.  Geoghegan  of  Kildare.  The  older  writers  make  frequent 
allusions  to  examples  of  this  latter  form  of  hemorrhage. 


SCARLATINA.  343 

''On  or  about  the  18tli  of  September,  1841,  Master ,  aged- 
eleven,  was  attacked  with  scarlatina.  He  was  of  remarkably  fair  com- 
plexion, thin,  almost  transparent  skin,  and  hair  nearly  white.  The  dis- 
ease assumed  rather  a  mild  form,  the  eruption  came  out  abundantly  and 
began  to  disappear  about  the  evening  of  the  fifth  day.  The  throat  was 
slightly  engaged — very  little  difficulty  in  swallowing;  but  there  were 
three  or  four  external  tumours,  exactly  resembling  scrofulous  glands, 
about  to  suppurate,  and  there  was  discharge  of  puriform  matter  from 
both  ears,  with  slight  deafness  of  the  left. 

^''  At  the  end  of  about  ten  days  he  seemed  to  be  progressing  favour- 
ably as  to  health ;  two  of  the  little  glands  on  the  left  side  suppurated 
and  were  opened,  discharging  healthy  pus;  his  appetite  was  pretty 
good  and  his  sleep  sufficient,  but  he  always  rested  during  the  day,  and 
remained  awake  during  the  night.  The  discharge  from  the  ears  con- 
tinued, and  he  had  become  quite  deaf  at  the  left  side. 

"  Soon  after  (I  cannot  be  particular  as  to  dates)  a  gland  on  the  right 
side  suppurated,  and  was  opened.  The  discharge  was  healthy ;  but 
that  from  the  right  ear  began  to  be  thin  and  abominably  fetid,  the 
smell  evidently  indicating  its  connexion  with  some  diseased  bone.  He 
was  now  totally  deaf  of  both  ears.  Our  communications  with  him 
were  altogether  by  signs,  and  he  was  becoming  paralytic  of  the  right 
side  of  the  face ;  all  his  features  being  drawn  frightfully  to  the  opposite 
side  when  he  either  laughed  or  cried.  At  the  end  of  about  six  weeks, 
however,  he  seemed  in  some  respects  to  be  greatly  improved.  He  slept 
well,  he  was  exceedingly  cheerful  and  even  lively,  and  his  appetite  al- 
most voracious.  He  had  so  far  recovered  his  hearing,  that  we  could 
communicate  easily  with  him ;  but  the  foul  discharge  continued  in  great 
abundance  from  the  right  ear,  and  the  paralysis  of  the  face  increased. 
He  continued  apparently  to  improve  in  general  health  and  even  in 
strength  until  the  end  of  the  ninth  week,  and  had  occasionally  been  up 
and  dressed  for  a  few  hours  in  the  day,  when  in  the  middle  of  the  night 
a  new  symptom  appeared. 

''  The  child  had  been  asleep,  when  he  suddenly  awoke,  screamed  out 
'  Oh,  my  ear,  my  ear !'  when  almost  instantly  a  gush  of  blood  took 
place  from  the  right  ear.  This  blood  was  florid,  and  had  the  appear- 
ance of  being  arterial.  It  came  gushing  forth  most  profusely  as  if 
poured  from  the  hp  of  a  jug  or  ewer,  and  was  sufficient  in  quantity  to 
soil  several  towels  before  it  ceased,  which  it  did  rather  from  the  exhaus- 
tion of  the  patient  than  from  the  means  employed  to  control  it.  I  was 
not  called  during  this  first  bleeding,  but  saw  him  early  next  morning. 
He  complained  of  dreadful  pain  in  the  left  side  of  the  head,  resem- 
bling hemicrania.     The  discharge  from  the  ear  was  a  thin  fetid  serum 


344(  CLINICAL   MEDICINE. 

mixed  with  flakes  of  unliealthy  matter  and  discoloured  with  blood; 
and  the  paralysis  of  his  face  greatly  increased,  the  features  being  distor- 
ted even  when  at  rest.  I  attempted  to  plug  the  ear ;  but  the  pressure 
interfering  with  the  discharge  of  matter,  caused  intense  pain,  and  could 
not  be  endured  even  for  a  few  minutes.  From  this  time  he  continued 
to  bleed  at  irregular  intervals  until  his  death ;  and  as  I  was  present  on 
three  or  four  occasions,  I  shall  endeavour  to  describe  one  of  the  attacks 
of  hemorrhage. 

"  He  seemed  to  have  no  previous  warning  whatever  :  sometimes  the 
bleeding  commencing  during  sleep,  sometimes  while  he  was  amusing 
himself  with  his  toys.  He  generally  gave  a  single  scream  at  the  in- 
stant, and  then  the  blood  burst  forth  with  a  gush  that  really  astonished 
me.  I  never  saw  blood  lost  so  rapidly  in  any  surgical  operation  I  ever 
witnessed,  and  only  once  in  an  accident  where  the  deep  jugular  vein 
had  been  opened.  This  bleeding  could  hardly  be  controlled  by  pressure, 
and  the  attempt  to  do  so  caused  intense  pain,  so  that  at  times  the  nurse 
did  not  interfere,  but  allowed  it  to  stop  spontaneously,  which  it  gene- 
rally did  in  about  a  minute.  The  blood  was  always  florid.  The  attacks 
occurred  at  irregular  periods,  and  there  never  was  hemon-hagic  fever. 

"  About  a  week  before  his  death,  I  observed  that  the  blood  was  be- 
ginning to  make  its  way  by  the  eustachian  tube  into  the  pharynx,  some 
of  which  passed  into  the  stomach,  and  some  was  expelled  by  the  mouth, 
and  then  he  bled  sometimes  by  one  passage,  sometimes  by  the  other, 
and  occasionally  by  both.  I  need  not  say  that  he  became  pale,  ex- 
sanguine, and  exhausted,  except  to  express  surprise  that  any  child  of 
his  age  could  have  endured  so  long.  The  palate  and  inside  of  liis 
mouth  was  as  pale  as  any  part  of  the  external  surface  of  his  body. 
Exactly  at  the  end  of  the  thirteenth  week  from  the  commencement  of 
his  illness,  he  died  after  a  shght  gush  of  blood. 

"  There  was  no  post-mortem  examination,  and  knowing  the  feelings 
of  the  child^s  parents  I  did  not  ask  it ;  therefore,  the  pathology  of  this 
case  must  be  matter  of  conjecture.  I  think  there  can  be  no  doubt 
that  there  was  caries  of  some  portion  of  the  base  of  the  skull,  and 
from  the  symptoms,  I  always  imagined  it  to  be  seated  in  the  petrous 
portion  of  the  temporal  bone.  The  spot  at  which  the  carotid  artery 
enters  this  bone,  is  immediately  adjacent  to  the  bony  portion  of  the 
eustachian  tube,  and  it  is  probable  that  this  latter  was  the  original  seat 
of  the  disease,  from  which  it  spread,  until  it  implicated  the  vessel. 
The  extraordinary  size  of  the  stream  satisfied  me  of  its  being  furnished 
by  some  large  vessel ;  its  colour  shewed  it  to  be  arterial ;  its  escape  by 
the  ear,  and  afterwards  by  the  mouth  and  nose,  proved  its  passage  by 
the  eustachian  tube ;  and  I  know  of  no  vessel  that  would  be  sufficient 


DIFFUSE    INFLAMMATION    OF   THE   NECK    IN    SCAHLATINA.         845 

to  explain  all  the  symptoms,  unless  the  one  I  have  mentioned — the 
internal  carotid/' 

With  reference  to  the  diffuse  inflammation  of  the  neck  that  follows 
scarlatina,  as  described  by  Dr.  Osbrey,  my  experience  accords  with  his ; 
and  the  recommendation  to  direct  all  our  efforts  to  the  support  of  the 
patient  until  the  period  of  sloughing  arrives,  deserves  the  greatest 
attention.  The  following  case  occurred  a  short  time  ago  at  the  Meath 
Hospital : — A  child  four  years  old  was  admitted  on  the  fourteenth  day 
of  its  illness,  with  the  integuments  in  tlie  front  of  the  neck  in  a  state  of 
gangrene.  In  a  day  or  two  the  sloughs  separated,  leaving  the  muscles 
of  the  neck  completely  bare,  and  as  distinct  from  each  other  as  if  dis- 
sected. The  common  carotids  were  also  laid  bare,  and  could  be  seen 
pulsating  at  the  bottom  of  the  ulcer.  A  few  days  after,  granulations 
sprung  up,  and  the  ulcerated  surface  soon  cicatrized.  I  have  not  been 
able  to  ascertain  if  any,  or  what  amount  of  contraction  of  the  neck 
followed  the  healing  of  the  ulcer. 

Sir  H.  Marsh  and  I  attended,  not  long  since,  a  lady  who  had  been 
affected  for  some  days  with  fever  and  sore  throat.  She  had  no  eruption 
on  any  part  of  her  body ;  but  from  the  character  of  the  fever,  and  the 
peculiar  appearance  of  the  throat,  we  suspected  she  was  labouring 
under  an  attack  of  scarlatina.  Her  family  were  very  anxious  to  ascer- 
tain the  precise  nature  of  her  complaint ;  and  I  visited  her  twice  a-day 
for  the  first  four  or  five  days  of  her  illness,  carefully  examining  the  skin 
at  each  visit,  but  could  not  discover  the  shghtest  trace  of  an  efflores- 
cence of  any  description.  She  continued  for  several  days  to  suffer  from 
the  fever  and  sore  throat,  and  was  at  one  time  in  a  dangerous  condi- 
tion, but  ultimately  recovered  by  great  care  and  the  use  of  appropriate 
remedies. 

Now,  I  watched  this  case  from  the  sixth  hour  after  its  commencement 
to  its  termination,  and  repeatedly  examined  the  skin,  particularly  that 
of  the  breast,  abdomen,  and  inside  of  the  knee  and  elbow  joints,  places 
in  which  the  eruption  shows  itself  when  it  appears  at  all,  but  could  not 
discover  any  vestige  of  it.  You  wiU  often  find  a  diffused  redness  about 
the  knees  and  elbows  in  cases  where  the  eruption  does  not  appear  on 
any  other  part  of  the  body ;  but  in  this  instance  there  was  not  the 
slightest  deviation  from  the  natural  hue.  Yet  the  result  proved  that  it 
was  scarlatina  ;  for  the  desquamation  of  the  cuticle,  which  always 
attends  this  disease,  took  place,  and  the  lady  communicated  the  infec- 
tion to '  several  members  of  the  family.  A  young  gentleman  residing 
in  the  house  got  a  bad  attack  of  scarlatina;  two  of  the  servants  were 
also  attacked,  and  the  lady's  father  got  sore  throat ;  in  fact,  there  could 
be  no  doubt  as  to  the  nature  of  the  disease.     During  her  convalescence 


346  CLINICAL    MEDICINE. 

she  had  desquamation  of  the  cuticle ;  and  this  is  a  point  to  which  I 
would  particularly  call  your  attention.  We  are  taught  to  look  upon 
desquamation  as  the  result  of  cutaneous  affections  of  an  inflammatory 
character  :  and  it  is  an  opinion  very  generally  maintained,  that  in  scar- 
latina, as  in  psoriasis,  the  peeling  off  of  the  cuticle  depends  on  the 
pecuhar  state  of  the  skin  produced  by  inflammation.  It  is  stated,  that 
the  increased  vascularity  of  the  skin  occasions  a  morbid  secretion,  and 
subsequent  detachment  of  the  epidermis,  and  that  the  same  phenomenon 
is  observed  in  all  cutaneous  affections  of  an  inflammatory  character. 
This  may  be  generally,  but  not  universally  true ;  for  here  we  had  an 
extensive  desquamation  of  the  cuticle  without  any  eruption,  without 
any  previous  redness,  pain,  or  remarkable  heat ;  in  fact,  without  any 
of  the  phenomena  which  are  regarded  as  constituting  inflammation. 
This  seems  to  prove  that  there  is  something  more  than  inflammation 
concerned  as  preparatory  to  that  process  which  is  termed  desquamation, 
and  that  the  change  which  the  skin  undergoes  is  not  to  be  looked  upon 
as  a  mere  consequence  of  inflammation  occupying  the  external  surface 
of  the  corium. 

I  observed  another  curious  fact  in  this  lad/s  case.  Since  the  attack 
which  I  have  just  described,  she  has  been  shedding  her  nails ;  that  is 
to  say,  the  nails  of  the  fingers  are  all  dropping  off,  and  yet  there  is  no 
appearance  of  inflammation  of  any  kind  about  the  hands  to  explain  the 
occurrence.  You  are,  of  course,  all  aware  that  the  dropping  off  of 
the  nails  is  a  species  of  desquamation.  Prom  the  peculiar  structure  of 
the  nail,  and  the  mode  in  which  it  is  formed  in  the  matrix,  it  does  not 
drop  off  at  once  like  a  scale  of  epidermis ;  still  I  think  we  are  autho- 
rised in  looking  upon  the  shedding  of  the  nails  as  a  species  of  desqua- 
mation. This  affords  a  very  curious  subject  of  investigation,  as  con- 
nected with  the  history  of  fever.  It  is  an  opinion  entertained  by  many 
persons,  that  desquamation  of  the  skin  takes  place  at  a  particular 
period  of  tj^hus  ;  and  that  this  is  not  an  occasional,  or  varying,  but  a 
constant  and  general  phenomenon.  This  statement  has  been  put  for- 
ward most  strongly  by  Dr.  Perry,  of  Glasgow ;  and  he  is  also  of  opinion, 
that  the  period  in  which  typhus  is  most  contagious,  is  during  the  des- 
cjuamation  of  the  cuticle.  It  is  also  asserted,  that  scarlatina  is  more 
contagious  during  desquamation  than  at  any  other  period  of  the  disease. 
This  is  at  least  the  popular  idea.  How  true  it  may  be,  my  experience 
or  observation  does  not  enable  me  to  decide ;  nor  am  I  prepared  to 
offer  anything  like  an  explanation  of  the  occurrence.  All  I  shall  say 
on  the  present  occasion  is,  that  the  occurrence  of  desquamation  of  the 
cuticle  in  typhus,  and  in  cases  of  scarlatina  without  eruption,  has 
greatly  altered  my  ideas  as  to  the  connexion  bet^veen  it  and  cutaneous 


ABSENCE    01'    ERUPTION    IN    SCARLATINA.  347 

inflammation.  I  think^  at  least,  that  the  process  of  desquamation  in 
such  cases  is  very  different  from  inflammation,  and  that  the  morbid 
action  of  which  desquamation  is  the  result,  has  very  little  in  common 
with  the  ordinary  process  of  inflammation  of  the  cutaneous  surface. 

A  gentleman  who  is  in  the  habit  of  attending  my  lectures  informs 
me  that  he  has  seen  three  cases  of  this  form  of  scarlatina,  characterised 
by  the  absence  of  the  external  efflorescence.  They  occurred  in  young 
persons,  after  puberty,  and  between  the  ages  of  fifteen  and  twenty-five. 
Each  of  these  cases  exhibited  a  considerable  degree  of  fever,  with  in- 
creased quickness  of  pulse,  thirst,  heat  of  skin,  diminution  of  the 
urinary  secretion,  and,  after  the  first  or  second  day,  much  depression, 
which  continued  for  two  or  three  days,  and  then  yielded  to  treatment. 
The  tongue  was  moist  but  pointed,  tremulous,  red,  and  injected. 
The  velum,  isthmus  faucium,  tonsils,  and  upper  part  of  the  pharynx, 
Avere  somewhat  swollen,  and  of  a  very  peculiar  dark  red  colour,  the 
redness  being  general,  and  equally  diffused  over  the  whole  of  the  upper 
part  of  the  pharynx,  as  far  as  it  could  be  examined. 

But  the  following  case,  which  was  very  lately  communicated  to  me 
by  a  practitioner  of  very  great  eminence  in  this  city,  is  still  more  cu- 
rious. Some  years  ago  scarlatina  broke  out  in  this  gentleman^s  family, 
and  attacked  all  his  children,  with  the  exception  of  one  young  lady, 
Avho,  although  in  constant  attendance  on  her  sisters  during  their  illness, 
did  not  exhibit  any  symptoms  whatsoever  of  the  disease.  When  all  the 
children  had  become  convalescent,  they  were  removed  to  the  country 
for  the  benefit  of  air,  whither  she  also  accompanied  them.  Here  she 
was,  much  to  the  astonishment  of  her  family,  attacked  with  the  peculiar 
anasarca  observed  in  persons  who  have  recently  laboured  under  scarla- 
tina. Her  father,  under  whose  observation  she  had  been  during  the 
whole  time,  was  very  much  struck  with  the  occurrence ;  he  paid  par- 
ticular attention  to  the  case,  and  feels  convinced  that  it  was  the  result 
of  latent  scarlatina.  This  case,  connected  with  those  already  detailed, 
is  of  great  interest  in  a  general  pathological  point  of  view.  It  appears 
to  prove  the  fact,  that  in  some  instances  diseases  produced  by  contagion 
do  not  give  rise  to  the  whole  train  of  phenomena  by  which  they  are 
ordinarily  characterised. 

Let  us  turn  for  a  moment  to  some  of  those  diseases  caused  by  the 
action  of  animal  poisons  on  the  system,  as,  for  instance,  measles. 
The  symptoms  which  generally  attend  and  characterise  measles  are 
universally  known.  After  an  attack  of  fever,  on  the  third  or  fourth 
day,  coryza,  sneezing,  hoarseness,  and  cough,  are  complained  of,  and 
then  a  rash  appears,  first  on  the  face,  and  afterwards  on  the.  body  and 
limbs.     But  it  is  not  necessary  that  all  these  symptoms  should  appear. 


348  CLINICAL    MEDICINE. 

and  that  the  sequence  of  morbid  phenomena  should  be  uninterrupted 
throughout ;  on  the  contrary,  it  frequently  happens  at  particular  periods, 
and  in  certain  constitutions,  that  some  of  the  most  usual  symptoms  are 
scarcely  observed,  or  altogether  absent.  You  will  find  this  point  in- 
sisted on  by  Dr.  Bateman,  who  has  given  a  detailed  description  of  a 
form  of  measles  in  which  the  catarrhal  symptoms  are  wanting,  and 
which  he  has  termed  rubeola  sine  catarrho.  Thus  we  may  have  pneu- 
monia without  cough,  and  pleuritis  without  pain  in  the  side.  Those 
who  have  witnessed  the  course  of  epidemic  cholera  in  this  country,  will 
recollect  that  many  cases  occurred  in  which  vomiting,  purging,  or  cramps 
were  not  observed. 

If  we  turn  to  fever,  we  find  that  the  animal  poison  to  which  it  owes 
its  origin  generally  exhibits  a  certain  number  of  symptoms,  congregated 
together,  or  observing  a  determined  order  and  succession ;  and  these  we 
meet  with  in  most  of  the  cases  which  come  before  us  in  practice.  But 
we  now  and  then  see  fever  patients  in  whom  one  or  more  of  the  most 
prominent  symptoms  are  absent.  Thus  occasionally  there  is  no  quickness 
of  pulse  or  appearance  of  vascular  excitement ;  in  some  there  are  no 
cerebral  symptoms ;  in  others  no  increase  in  the  temperature  of  the  skin. 
Indeed,  I  might  go  through  the  whole  group  of  symptoms  which  accom- 
pany fever,  and  show  that  almost  every  one  of  them  may  be  occasionally 
absent,  and  yet  the  fever  of  a  severe  and  dangerous  type.  I  recollect 
pointing  out  to  the  class  last  year  the  case  of  a  man  labouring  under 
chronic  enlargement  of  the  spleen.  He  had  been  working  for  two  or 
three  seasons  in  some  of  the  marshy  districts  of  England,  and  had  been 
occasionally  ill,  but  never  had  symptoms  of  regular  intermittent ;  in  fact, 
he  had  escaped  the  intermittent  itself,  but  not  what  are  usually  deemed 
the  consequences  of  it.  "We  have  been  in  the  habit  of  explaining  the 
enlargement  of  the  spleen  by  referring  it  to  the  conflux  of  blood  towards 
the  internal  organs,  particularly  the  liver  and  spleen,  during  the  cold 
stage  of  intermittent ;  and  we  have  endeavoured  to  explain  the  subcuta- 
neous cedema  which  follows  scarlatina,  by  attributing  it  to  previous  in- 
flammation of  the  skin  and  subcutaneous  areolar  tissue ;  but  the  obser- 
vations and  facts  which  I  have  now  brought  forward  will  show  that  these 
opinions  were  founded  on  erroneous  ideas. 

Turning  to  cases  of  chronic  disease,  we  find  in  some,  as  for  instance 
syphihs,  that  the  poison  taken  into  the  system,  gives  rise  in  most  cases 
to  a  determinate  order  of  symptoms,  e.  g.  bubo,  sore  throat,  eruptions 
on  the  skin,  nodes,  and  syphilitic  cachexy.  Mr.  Hunter  has  been  at  great 
pains  in  determining  the  order  of  the  parts,  and  pointing  out  the  tissues 
which  are  successively  affected,  and  it  is  of  considerable  importance  to 
have  correct  notions  on  this  point ;  but  although  the  number  and  order 


ANASARCA    ATTEE,   SCAULATINA.  349 

of  symptoms  marked  out  by  Mr.  Hunter  and  others  may  be  observed  in 
most  casesj  they  are  not  so  in  all ;  and  the  same  remark  which  has  been 
made  on  the  occasional  absence  of  one  or  more  important  symptoms^  in 
scarlatina,  will  apply  with  equal  force  to  syphilis.  Now  when  this  morbid 
poison  which  excites  syphilis  does  not  affect  the  constitution  in  such  a 
manner  as  to  occasion  the  production  of  all  the  symptoms  which  usually 
characterize  this  disease,  a  variety  of  venereal  is  formed,  which  often 
proves  a  source  of  great  embarrassment,  not  only  to  the  young  and  inex- 
perienced, but  even  to  the  senior  members  of  the  profession. 

It  is.  of  great  consequence,  in  a  practical  point  of  view,  to  bear  in 
mind  the  general  proposition  I  have  announced,  viz.,  that  in  both  acute 
and  chronic  diseases  a  constitutional  affection  may  dis])lay  its  existence 
hy  only  one  or  two  of  the  numerous  symptoms  which  usually  accompany 
it :  and  this  occurrence  seems  more  frequent  in  the  case  of  diseases  pro- 
duced by  contagion  and  morbid  animal  or  vegetable  poisons,  than  in  the 
case  of  maladies  generated  by  causes  developed  in  the  system  itself. 

The  case  of  William  Young,  who  was  admitted  on  Wednesday  last, 
has  some  claims  to  your  attention,  and  demands  a  few  observations  on 
my  part.  This  boy,  who  is  about  twelve  years  of  age,  had  an  attack  of 
scarlatina  some  time  ago,  and  had  been  dropsical  for  a  week  or  ten  days 
at  the  period  of  his  admission.  He  was  somewhat  feverish,  had  thirst, 
heat  of  skin,  and  slight  headache,  cough,  and  difficulty  of  breathing,  and 
on  making  an  examination  with  the  stethoscope,  we  detected  numerous 
bronchial  rales ;  his  lower  extremities  were  anasarcous,  and  he  had  some 
effusion  into  the  peritoneal  sac.  We  could  not  ascertain  exactly  the 
time  when  this  train  of  symptoms  commenced,  but  it  is  very  probable 
that  it  was  a  week  or  ten  days  after  the  disappearance  of  scarlatina. 
Wlien  patients  who  have  been  recently  labouring  under  an  attack  of 
scarlatina  take  cold,  the  anasarcous  symptoms  appear  in  a  very  short 
time  after  the  attack ;  but  even  where  they  are  not  exposed  to  cold,  the 
dropsy  appears  generally  about  ten  days  or  a  fortnight  after  scarlatina, 
and  is  very  often  accompanied  by  some  pectoral  affection.  The  disease 
sets  in  with  febrile  exacerbations  more  or  less  marked ;  anasarca  of  the 
extremities  is  next  noticed,  and  at  the  same  time  the  patient  has  slight 
cough  and  difficulty  of  breathing,  which  generally  proceeds  from  conges- 
tion of  the  bronchial  mucous  membrane,  but  may  be  the  result  (though 
less  frequently)  of  pleuritis  or  pneumonia. 

If  called  to  a  case  of  this  kind  in  the  commencement,  and  where  the 
patient  is  not  greatly  exhausted  by  previous  disease,  the  treatment  is 
exceedingly  simple.  By  opening  a  vein  in  the  arm,  and  abstracting  a 
quantity  of  blood  proportioned  to  the  age  and  strength  of  the  patient, 
you  remove  the  inflammatory  state  of  the  constitution,  and  arrest  at  once 


350  CLINICAL    MEDICINE. 

the  anasarcous  and  pectoral  symptoms.  It  may  occasionally  happen  that 
active  measures  of  this  kind  cannot  be  taken  in  consequence  of  the  great 
debility  of  the  patient  from  previous  disease ;  but,  generally  speaking, 
cases  of  anasarca  after  scarlatina  bear  antiphlogistic  treatment  well.  It 
is  not  after  cases  of  violent  scarlatina,  or  where  the  patient^s  life  has  been 
in  imminent  danger,  that  the  supervention  of  dropsy  is  most  commonly 
observed ;  the  majority  of  dropsical  cases  of  this  kind  are  met  with  in 
patients  who  have  had  the  disease  mildly,  and  without  any  remarkable 
intensity  either  of  the  local  or  general  symptoms.  Hence,  venesection 
is  borne  well,  and  its  performance  attended  by  the  most  decided  good 
effects,  particularly  where  the  dropsy  is  complicated  with  pleuritis  or 
pneumonia. 

In  the  case  before  us,  however,  being  uncertain  as  to  the  exact  dura- 
tion of  the  disease,  and  finding  several  symptoms  present  indicative  of 
weakness,  we  were  obliged  to  proceed  with  more  caution.  The  boy  had 
been  ill  a  week,  and  appeared  to  be  under  the  influence  of  digitalis 
administered  before  his  admission,  for  his  pulse  was  intermittent  and 
wavering.  Under  these  circumstances  I  determined  to  limit  the  anti- 
phlogistic measures  to  the  application  of  a  few  leeches  over  the  abdomen. 
I  did  this  with  less  hesitation,  as  an  accurate  examination  of  the  chest 
showed  that  there  was  neither  pleuritis  nor  pneumonia  present.  The 
internal  remedies  were  calculated  to  increase  the  secretion  from  the  kid- 
neys. The  boy^s  urine  was  remarkably  albuminous,  and  of  the  specific 
gravity  of  1027.  This  is  a  point  worthy  of  remark.  In  many  cases  of 
dropsy  after  scarlatina,  the  urine  is  albuminous.  Now,  almost  every  case 
of  this  kind  will  get  well,  and  as  convalescence  progresses,  you  will 
observe  that  the  urine  ceases  to  be  albuminous.  These  facts,  of  the  truth 
of  which  I  can  speak  with  the  fullest  confidence,  are  quite  sufficient  to 
show  that  those  persons  are  wrong  who  assert  that  albuminous  urine  is 
always  the  result  of  organic  disease  of  the  kidneys.  Albuminous  urine 
is  here,  as  Dr.  Blackall  observes,  merely  an  indication  of  a  peculiar  in- 
flammatory condition  of  the  whole  system,  and  not  of  degeneration  of  the 
kidneys."^  I  may  observe,  however,  that  this  is  not  invariably  the  case ; 
for  I  could  point  out  examples  where  albuminous  urine  is  connected  with 
an  apparently  opposite  condition  of  the  system ;  in  fact,  a  condition  de- 
manding the  use  of  a  generous  diet  and  tonics. 

Hence,  there  must  be  great  diversity  in  the  treatment  of  dropsy  with 
albuminous  urine.  Where  it  occurs  after  scarlatina,  and  is  accompanied 
by  febrile  symptoms,  it  is  best  treated  by  the  lancet,  nitre,  purgatives, 

*  These  opinions  have  been  since  advocated  by  Dr.  Burrows,  in  his  admirable  essay 
on  Scarlatina,  published  in  the  "  Library  of  Medicine^^*  Vol.  1.,  and  which  I  feel  great 
pleasure  in  recommending. 


ANASARCA    AFTER   SCARLATINA.  351 

and  digitalis ;  but  where  it  occurs  in  clironic  cases,  without  any  remark- 
able excitement  of  the  vascular  system,  without  organic  disease,  and 
with  more  or  less  debility,  it  requires  to  be  treated  with  tonics,  generous 
diet,  and  full  doses  of  opium.  In  the  present  case  I  only  applied  a  few 
leeches  to  the  belly,  and  kept  the  bowels  gently  open  for  the  first  few 
days,  being  determined  to  wait  until  the  pulse  became  regular  before  I 
ventured  on  any  decided  plan  of  treatment.  I  then  ordered  mercurial 
frictions  to  the  abdomen  and  axillse,  and  gave  mercury  internally  com- 
bined witli  small  quantities  of  digitalis.  He  also  got  a  draught  twice  a 
day  composed  of  carbonate  of  soda,  tincture  of  squill,  and  syrup  of 
orange  peel.  These  remedies  we  shall  continue  for  some  time,  carefully 
watching  their  effects. 

Erom  the  state  of  weakness  this  boy  was  in  at  the  period  of  his  ad- 
mission, and  the  length  of  time  the  disease  has  lasted,  I  have  not 
thousjht  it  advisable  to  bleed  him.  When  cases  of  this  kind  become 
chronic,  they  are  very  difficult  of  cure,  and  require  very  delicate  manage- 
ment. You  will  frequently  have  to  run  through  the  whole  list  of  reme- 
dies employed  on  such  occasions,  before  you  can  hit  on  one  that  proves 
successful.  I  recollect  a  case  of  tliis  kind,  in  which  the  anasarca  was 
extreme,  and  the  bo/s  legs  were  enormously  swollen ;  the  dropsy  was 
accompanied  by  scanty  secretion  of  urine,  but  without  any  distinct 
febrile  excitement.  After  having  used  every  remedy  I  could  think  of, 
for  nearly  three  months,  without  any  benefit,  I  resolved  to  try  the  effects 
of  cold  affusion,  from  which  I  had  experienced  much  advantage  some 
time  previously  in  another  case.  I  ordered  a  large  vessel  filled  with 
pump  water,  in  which  a  quantity  of  salt  had  been  dissolved,  to  be 
poured  over  him  twice  a  day,  for  the  space  of  two  or  three  minutes  each 
time,  immediately  after  which  the  boy  was  wiped  perfectly  dry  and  put 
to  bed.  The  good  effects  of  this  measure  became  soon  evident;  a 
copious  discharge  of  urine  took  place,  the  ■  swelling  of  the  limbs  sub- 
sided, and  in  about  six  or  seven  days  the  child  was  able  to  run  about  as 
usual. 

This  case  went  on  unfavourably,  and  the  boy  died,  after  lingering 
several  weeks,  in  a  state  of  extreme  dropsical  swelling  and  great  suffer- 
ing, distention,  and  dyspnoea.  As  his  urine  continued  highly  albumi- 
nous throughout,  we  were  excessively  curious  to  learn  what  was  the 
condition  of  his  kidneys.  The  post-mortem  examination  was  made  a 
few  hours  after  death,  and  the  kidneys  were  found  in  every  respect 
healthy ;  their  size,  shape,  consistence,  and  colour,  were  perfectly  normal. 
The  long-continued  presence  of  albuminous  urine,  in  a  case  where  no 
such  state  of  kidney  existed,  forms  conclusive  evidence  that  this  state  of 
urine  is  not  necessarily  the  result  of  that  renal  degeneration  first  de- 


352  CLINICAL   MEDICINE. 

scribed  by  Dr.  Bright ;  the  occurrence  of  one  positive  exception  is  suf- 
ficient to  disprove  such  a  conclusion^  even  though  supported  by  a  thou- 
sand cases,  and,  consequently,  when  albuminous  urine  in  chronic  dropsy 
is  found  to  occur  along  with  Brighf  s  kidney,  I  consider  this  particular 
state  of  urine  and  of  kidney,  as  depending  upon  different  causes,  which 
often  co-exist  in  chronic  dropsy,  and  consequently  I  regard  albuminous 
urine  as  a  sign  of  Bright's  kidney,  but  not  as  its  result. 

It  has  been  already  observed  that  anasarca  seldom  occurs  after  severe 
and  dangerous  scarlatina,  but  is  not  unfrequent  as  a  sequela  of  the  very 
mildest  forms  of  that  disease ;  a  fact  of  which  every  practitioner  should 
be  aware,  and  a  knowledge  of  which  should  prevent  us  from  pro- 
nouncing a  patient  out  of  danger  until  the  period  during  which  dropsy 
may  supervene,  is  passed.  To  impress  the  necessity  of  caution,  I  may 
mention  that  I  have  seen  several  cases  of  scarlatina  in  young  persons 
and  children  so  mild  as  not  to  require  confinement  to  bed,  and  yet  fol- 
lowed about  the  18th  or  20th  day,  by  anasarca ;  this  usually  yields  to 
treatment  without  much  trouble,  but  in  some  patients,  and  without  our 
being  able  to  assign  any  cause  for  it,  the  anasarca  increases  rapidly,  .the 
pulse  rises,  and  in  a  few  days  is  excessively  rapid,  from  180  to  150,  be- 
coming hourly  weaker  and  weaker  while  the  heart's  action  is  strong  and 
tumultuous ;  the  skin  is  hot,  and  in  many  individuals  infiammatory 
symptoms  manifest  themselves  in  the  head,  chest,  or  belly,  and  the  pa- 
tient is  carried  off  by  internal  inflammatory  effusion  into  one  or  other  of 
these  cavities.  Other  cases  are  more  treacherous,  and  the  approach  of 
danger  is  not  indicated  by  anything  but  the  rising  of  the  pulse,  and  the 
rapid  increase  of  the  dropsical  effusion,  soon  to  be  followed  by  convul- 
sions that  succeed  each  other  until  death  closes  the  scene,  a  termina- 
tion so  much  the  more  unexpected,  as  these  cerebral  symptoms  have  not 
been  preceded  by  the  least  headache,  or  any  perceptible  affection  of  the 
functions  of  the  brain ! 

In  addition  to  the  remedies  already  mentioned,  I  can  speak  with  the 
greatest  confidence  of  the  utility  of  hydriodate  of  potash  in  the  form  of 
anasarca  we  are  now  treating  of;  and  I  may  add,  that  I  have  found 
the  following  line  of  treatment  more  successful  than  any  other  in  the 
malignant  forms  of  scarlatina — local  bleeding  by  leeches  when  neces- 
sary ;  wine  and  carbonate  of  ammonia  freely  given,  with  camphor  mix- 
ture. In  some  cases  attended  with  intense  heat  of  the  skin,  the  cold 
affusion  has  given  great  relief,  in  others  it  has  failed. 


353 


LECTURE  XXV. 

INTERMITTENT  FEVER. DISEASES  WHICH  SIMULATE  IT. THE  MALARIOUS 

FEVER   OF   AFRICA. 

I  PURPOSE  devoting  to-day's  lecture  to  the  consideration  of  some  points 
connected  with  intermittent  fever,  most  of  which  I  was  the  first  to  ob- 
serve and  describe.  I  will  first  read  for  you  the  notes  of  a  case  of 
intermittent  fever,  reported  by  Mr.  Power  : — 

Mary  Gannon,,  aged  44,  was  attacked  by  intermittent  fever  about  the 
middle  of  September  last.  The  paroxysms  occurred  twice  every  day, 
one  in  the  morning,  the  other  in  the  afternoon,  for  the  space  of  ten 
days,  after  which,  owing  to  medical  treatment,  the  evening  one  dis- 
appeared. On  the  10th  of  October  she  was  admitted  into  the  Meath 
Hospital,  and  was  placed  under  the  care  of  Dr.  Stokes,  who  prescribed 
small  doses  of  sulphate  of  quina,  under  the  use  of  which  the  fit  became 
tertian,  but  soon  afterwards  returned  to  the  quotidian  form.  On  the 
1st  of  November  she  became  a  patient  to  Dr.  Graves,  and  was  put  on 
large  doses  of  the  sulphate  of  quina.  On  the  7th  of  the  same  month, 
the  fit  again  assumed  the  tertian  form,  in  which  state  it  continued  until 
the  17th,  although  the  dose  of  quina  had  been  increased  to  a  scruple 
and  a  half  in  the  day.  She  was  then  blooded  to  5xviij.,  by  which  the 
duration  of  the  paroxysm  was  lessened,  and  the  interval  between  it  and 
the  succeeding  one  increased  by  twelve  hours.  She  was  again  blooded, 
and  the  fit  became  quartan.  Yenesection  was  repeated  for  three  times, 
but  without  any  other  sensible  effect  than  a  curtailment  of  the  duration 
of  the  existing  paroxysm.  Her  strength  now  became  reduced,  and  she 
was  ordered  to  take  four  drops  of  the  liquor  arsenicalis  in  half  an  ounce 
of  mint  water,  three  times  a  day.  Since  she  commenced  taking  the 
arsenic,  the  violence  of  the  paroxysms  has  been  gradually  subsiding, 
and  strength  and  appetite  are  returning;  at  present,  the  fit  presents 
scarcely  any  other  characters  than  those  of  a  slight  shivering. 

Now,  what  is  the  definition  of  a  quartan  ague.     According  to.  Cullen, 
it  consists  of  paroxysmi  similes  intervallo  septuaginta  duarum  circiter 

VOL.  I.  23 


354  CLINICAL   MEDICINE. 

lioramm ;  accessionibus  pomericlianis,"  that  is  to  say,  the  attacks  must 
be  similar,  there  must  be  an  interval  of  72  hours  between  them,  and 
the  fit  is  to  come  on  in  the  afternoon.  Let  us  examine  how  far  the 
characters  of  the  present  case  coincide  with  this  definition.  Latterly, 
she  had  seven  attacks  wdth  a  precise  interval  of  72  hours  ;  in  the  next 
place  the  attacks  were  similar ;  so  far  so  good ;  but  the  accessions  of 
her  paroxysms  were  in  the  forenoon  and  not  in  the  afternoon,  for  they 
generally  came  on  about  eight  o^ clock  in  the  morning,  and  in  this 
respect  accommodated  themselves  to  our  convenience,  for  we  could  be 
here  to  witness  them.  It  is  very  true  that  we  generally  find  the  pa- 
roxysm of  quotidian  in  the  morning,  of  tertian  in  the  middle  of  the  day, 
and  of  quartan  in  the  evening,  and  also  that  one  may  pass  into  the 
other,  but  to  this  I  do  not  attach  much  importance.  Here  the  disease 
evidently  terminated  by  becoming  quartan.  A  question  arises  as  to 
what  w^as  the  nature  of  the  fever  in  the  commencement  ?  Was  it  any 
variety  of  quartan  ?  that  is,  was  it  quartan  disguised  under  the  type  of 
any  other  species  of  intermittent?  In  the  beginning,  she  had  two 
paroxysms  every  day,  constituting  what  has  been  termed  the  quotidiana 
duplex,  a  disease  which  is  common  enough,  though  it  has  not  been 
noticed  by  Cullen  in  liis  Nosology.  The  nearest  approach  which  the 
first  form  of  our  case  makes  to  the  acknowledged  quartan  of  authors,  is 
to  the  quartana  triplex,  w^here  we  have  the  fit  coming  on  three  times  a 
day,  with  every  fourth  paroxysm  similar.  But  you  perceive,  plainly, 
that  Gannon's  fever,  in  its  first  form,  is  not  reconcilable  to  any  known 
type  of  quartan  ague. 

Now,  what  was  the  effect  of  the  remedies  employed  ?  Eirst  to  make 
it  assume  the  form  of  a  simple  quotidian,  and  as  a  still  further  improve- 
ment, resolve  this  into  a  tertian.  Here  we  have  an  argument  against 
the  supposition  of  a  concealed  quartan,  for  an  interval  of  48  cannot, 
by  doubling,  be  converted  into  an  interval  of  72.  But  the  effect  of 
remedies,  nevertheless,  produced  this  anti-nosological  conversion,  for 
the  first  bleeding  in  the  cold  stage  made  an  addition  of  12  hours  to  the 
tertian  interval ;  and  a  second  bleeding  added  another  12  hours,  and 
then  we  had  the  quotidian  interval  complete.  This  was  indeed  a  hit- 
and-bit  reform  of  a  double  quotidian  into  a  simple  quartan. 

Let  us  review  the  length  of  the  intervals  in  a  series  of  numbers. 
First;  it  was  12  hours  for  the  space  of  10  days;  next,  24  hours  for 
several  days;  then,  48  hours  for  several  days;  again,  24  hours  for 
several  days,  then  48  for  several  days,  then  60  for  one  day,  and,  lastly, 
72  for  seven  days.  From  this,  I  think  we  may  conclude,  that  the  imit 
from  which  we  ought  to  set  out  in  calculating  intervals  should  be 
12  hours  between  the  accession  of  one  attack  and  the  accession  of  the 


INTERMITTENT   FEVER.  355 

next.  This  is  the  atom  on  which  all  our  computations  must  be  founded, 
for  its  multiples  include  all  the  varieties  of  intermittent  fever.  It  would 
appear,  that  instances,  where  the  fit  comes  on  earlier  than  was  expected, 
or  is  postponed  beyond  the  customary  period,  would  go  to  invalidate 
what  I  have  mentioned.  Such  cases,  however,  I  look  upon  as  only 
transition  stages  to  more  permanent  varieties. 

In  many  cases  of  quotidian,  it  has  been  observed  by  nosologists,  that 
every  second  fit  is  more  severe,  and  hence  they  have  termed  this  form 
the  tertiana  duplex.  The  chief  argument  in  support  of  this  opinion  of 
quotidians  becoming  tertians  is,  that  under  the  salutary  influence  of  our 
remedies,  they  become  tertians  before  they  cease  altogether.  In  answer 
to  this,  it  may  be  observed,  first,  that  this  is  not  ahvays  the  case; 
secondly,  when  it  does  take  place,  it  is  because  the  days  of  the  least 
severe  fits  are  of  course  those  on  which  they  soonest  cease,  in  con- 
sequence of  the  exhibition  of  bark,  or  sulphate  of  quina,  for  it  often 
happens  that  these  medicines  do  not  remove  the  aguish  fits  entirely  and 
at  once,  but  gradually,  and,  as  it  were,  by  wearing  down  the  paroxysms. 
Thus,  then,  a  quotidian,  such  as  we  have  described,  must,  if  gradually 
cured,  before  a  complete  cure  be  effected,  observe  the  tertian  interval^ 
but  still  it  is  not  a  true  tertian  at  any  period  of  its  duration. 

Hectic  fever,  notoriously,  has  intervals  of  1£  hours,  and  it  may  be 
observed,  that  many  circumstances  corroborate  the  opinion,  that  in 
naming  and  classifying  diseases,  it  is  more  consonant  with  the  laws  that 
regulate  the  diurnal  revolutions  of  the  animal  economy,  to  use,  as  our 
period,  12  hours,  whose  multiples  give  rise  to  the  different  intervals  of 
agues,  than  to  assume  24  hours,  as  the  term  from  which  we  are  to  com- 
mence our  calculations.  Thus  the  state  of  the  pulse,  according  to  the 
laborious  investigations  of  Nick,  have  shown,  that  a  regular  revolution, 
as  to  its  frequency,  takes  place  every  12  hours,  and  the  same  result  has 
been  made  with  regard  to  the  intensity  of  the  respiratory  process.  We 
all  know  that  there  is  a  considerable  difference  between  the  nervous  and 
calorific  powers  of  the  body  during  the  twelve  hours  we  spend  in  active 
employment  and  awake,  and  those  which  are  chiefly  passed  in  tran- 
quillity and  repose. 

As  the  average  period  of  day  'and  night  respectively  is  twelve  hours, 
in  the  same  manner  equivalent  spaces  of  time  seem  to  be  destined  for 
the  successive  and  alternating  revolutions  of  the  living  system.  It 
would  be  extremely  interesting  to  consider  what  influence  their  adop- 
tion might  have  in  our  calculations  concerning  the  crisis  of  continued 
fevers.  We  would  not  then  count  three  days  and  a  half,  but  seven  half 
days ;  we  would  not  say  seven  days,  but  fourteen  half  days.  If  this 
method  were  adopted,  many  of  the  apparently  anomalous  critical  effects 


356  CLINICAL   MEDICINE. 

and  critical  terminations,  in  continued  fevers,  would,  I  have  no  doubt, 
become  strictly  conformable  to  some  regular  law  of  periodicity.  To 
arrive  at  a  knowledge  of  this  law  would  be  of  the  greatest  importance, 
and  would  tend  much  to  render  our  knowledge  of  fevers  more  accurate, 
and  our  treatment  more  efficacious.  Those  who  entirely  deny  the 
critical  period  must  be  either  very  superficial  observers  or  very  indif- 
ferent practitioners.  In  private  practice,  where  the  precise  commence- 
ment of  the  attack  can  be  ascertained,  a  crisis,  or  an  obvious  attempt 
at  a  crisis,  takes  place,  often  on  the  reputed  critical  day,  occasionally  on 
others ;  and  if  the  treatment  be  judicious,  it  seldom  happens  that  a 
fever  terminates  without  either.  Within  the  last  year  I  have  seen  two 
cases,  in  which  a  decided  and  perfect  crisis  took  place  on  the  42d  day. 
In  another  case  a  salutary  crisis  took  place  on  the  35th  day.  The  first 
of  these  cases  I  saw  along  with  Dr.  Stokes ;  the  second,  with  Dr.  Plant ; 
the  third,  with  Mr.  Rumley.  In  another  case,  which  I  attended  with 
Mr.  Kirby,  there  was  an  obvious  but  unsuccessful  effort  at  crisis  on  the 
7tli,  14th,  21st,  28th  and  35th  days. 

I  must  admit  that  I  have  seen  perfect  crises  on  days  not  reputed  cri- 
tical ;  but  I  am  convinced,  that  if  the  method  of  counting  by  half  days 
and  not  by  days  were  adopted,  the  exceptions  to  the  occurrence  of  crisis 
would  be  much  less  numerous.  The  nature  of  a  crisis  has,  I  think, 
been  never  truly  explained.  To  me  it  appears  evident,  that  all  the 
phenomena  which  attend  this  curious  change  prove,  that  when  a  con- 
tinued fever  terminates  by  crisis,  it  is  hy  being  converted  into  a  fever  of 
a  new  type  and  shorter  duration.  A  well-marked  crisis  comes  on  almost 
like  a  fit  of  the  ague  ;  it  is  ushered  in  by  great  coUapse,  coldness,  and 
even  sometimes  by  rigor.  This  is  succeeded  by  a  hot  fit,  and  that  again 
by  a  sweating  stage,  copious  deposition  in  the  urine,  &c.  and  then  the 
patient  is  found  free  from  fever.  Is  it  not  probable,  therefore,  that  the 
crisis  is  not  merely  the  termination  of  the  former  fever,  but  a  new  fever, 
as  it  were,  superadded  to  it  for  the  purpose  of  exciting  a  change  in  the 
system,  attended  by  such  a  powerful  action  of  another  kind,  that  the 
former  chain  of  morbid  actions  is  broken,  and  the  tendency  of  the  new 
fever  to  terminate  in  health  is  thereby  allowed  to  prevail  ? 

To  many,  I  am  aware,  what  I  have  said  may  seem  fanciful,  but  to  a 
close  and  candid  observer  of  nature  tliis  hypothesis  may  not  appear 
altogether  unfounded. 

I  shall  not  detain  you,  gentlemen,  in  making  any  remarks  on  the 
treatment  pursued  in  Gannon's  case.  You  have  seen  how  the  sulphate 
of  quina  changed  the  type  of  the  fever,  and  you  observed  how  com- 
pletely the  liquor  arsenicalis  succeeded  in  removing  the  disease,  after 
other  remedies  had  failed.     It  is  to  be  recollected,  however,  that  con- 


i 


INTERMITTENT   I'EVER.  357 

siderable  advantage  was  derived  from  venesection  in  the  cold  stage^  and 
it  is  probable  that  this  treatment  by  the  lancet  was  a  useful  preparation 
for  that  by  arsenic.  It  has  been  supposed  that  bleeding,  during  the 
cold  stage  of  ague,  produces  a  favourable  effect,  in  consequence  of  its 
relieving  the  internal  sanguineous  congestion.  This  hypothesis,  how- 
ever, does  not  appear  well  founded,  for  the  utility  of  venesection  is  by 
no  means  confined  to  those  cases  of  intermittent  fever,  in  which  the 
cold  stages  are  attended  with  an  evident  diminution  in  the  external  cir- 
culation, denoted  by  a  shrunk  countenance,  cold  and  pointed  nose,  and 
a  pale  corrugated  skin.  In  such  cases  it  is  very  reasonable  to  conclude, 
that  the  internal  organs  must  labour  under  sanguineous  congestion,  as 
long  as  the  quantity  of  blood  in  the  periphery  of  the  body  is  diminished ; 
but  this  obvious  deviation  from  the  proper  balance  of  the  circulation 
is  not  observable  in  every  case ;  and  in  that  related  above,  the  tempera- 
ture of  the  external  parts  was  increased  at  the  very  moment  that  the 
violence  of  the  rigor  was  greatest,  while  at  the  same  time  the  extremi- 
ties, face,  and  general  surface  of  the  skin  appeared  to  enjoy  a  more 
than  usually  abundant  and  active  circulation.  We  must,  therefore, 
refer  the  benefit  derived  from  the  venesection  to  some  other  cause,  most 
probably  its  energetic  action  on  the  nervous  system ;  it  is  to  this  we 
must  attribute  its  effects  in  stopping  the  rigor  and  lengthening  the  in- 
termissions. 

That  the  rigor  of  ague  is  an  affection  chiefly  depending  on  the  ner- 
vous system  may  be  proved  by  many  circumstances,  but  by  none  more 
strongly  than  by  the  following  fact,  quoted  from  a  collection  of  Notices 
of  Eussia,  pubhshed  in  the  United  Service  Journal  for  January, 
1833  :— 

"In  Kasan  these  fevers  are  quotidian  or  tertian,  very  rarely  quartan, 
and  they  differ  from  the  agues  of  other  countries  in  this  respect,  that 
the  patient  experiences  scarcely  any  shivering,  but  feels  a  violent  twitch- 
ing in  the  spine,  which  is  soon  followed  by  excessive  heat  and  violent 
headache,  during  which  the  pulse  beats  like  a  hammer.  Eor  this  fever, 
the  Ptussian  physicians  resort  to  no  other  remedy  but  bark.''^ 

The  following  description  of  the  Eussian  province,  so  fertile  in  ague, 
is  weU  worthy  of  your  attention,  and  I  shall  make  no  apology  for  read- 
ing it  to  you: — 

"  The  summer  in  this  country  is  further  remarkable,  inasmuch  as 
from  tlie  end  of  May  to  the  beginning  of  September,  no  rain  falls,  and 
tliunder  storms  are  extremely  rare.  This  phenomenon  is  doubtless 
owing  to  the  flatness  of  the  country.  For  five  hundred  miles  and  more, 
around  Perm  and  Kasan,  there  is  not  a  hill  of  any  consequence,  and 
the  whole  tract  from  Kiew  to  Ural,  for  a  breadth  of  five  hundred  miles. 


358  CLINICAL   MEDICINE. 

may  be  called  a  plain,  only  here  and  there  interrupted  by  ranges  of 
gentle  hills.  The  extraordinary  fertility,  especially  of  the  government 
of  Kasan,  is  occasioned  by  the  inundation  of  the  Wolga,  which  over- 
flows annually  at  particular  seasons,  as  regularly  as  the  Mle  in  Egypt, 
and  converts  the  whole  country,  to  the  distance  of  ten  miles  or  more 
from  its  bed,  for  five  or  six  weeks,  into  an  immense  sea.  These  inun- 
dations of  the  Wolga,  and  the  other  large  rivers,  the  "Witjatka,  the 
Kama,  the  Kinel,  the  Irgis,  &c.,  which  discharge  themselves  into  the 
Wolga,  render  the  countries  through  which  they  flow  at  once  lively  and 
fertile.  At  such  seasons  you  may  sad,  either  for  pleasure  or  upon 
business,  in  large  two-masted  vessels,  carrying  from  six  to  ten  guns, 
over  pastures  and  corn  fields,  to  the  neighbouring  towns,  which  on  this 
account,  are  all  situated  upon  heights ;  and  when  the  waters  have  with- 
drawn into  their  accustomed  channels,  the  ground  forsaken  by  them  is 
covered,  often  a  yard  deep,  with  a  fertilising  mud,  in  which,  during  the 
hot  season,  all  vegetables  grow  rapidly  and  vigorously  as  in  a  hot-house. 
At  the  same  time  pools  are  left  behind  in  the  low  grounds,  where  the 
water  stagnates  for  several  months,  becomes  putrid  and  generates 
malignant  fevers  in  the  months  of  July  and  August  in  these  other- 
wise healthy  countries.  The  government  of  Ufa,  particularly,  is 
visited  about  that  time  by  an  intermittent  fever,  which  attacks  the 
patient  every  seventh  day  only,  but  is  so  violent,  that  it  generally  proves 
fatal." 

If  this  account  be  correct,  and  indeed  there  can  be  little  doubt  of 
its  accuracy,  a  new  species  of  ague  must  be  established,  and  to  the  quo- 
tidian, tertian,  and  quartan,  must  be  added  a  fourth  type,  whose  attacks 
return  every  seventh  day. 

In  Ireland  we  seldom  meet  with  cases  of  ague  with  paroxysms  so 
violent  as  to  endanger  the  patient^s  life.  I  lately  saw,  however,  a  case 
of  this  nature.  I  was  sent  for  in  a  great  hurry  to  visit  a  gentleman 
residing  in  the  neighbourhood  of  Donnybrook  ;  he  had  slept  well  until 
four  0^ clock  in  the  morning,  when  he  was  awakened  by  a  general  feehng 
of  malaise,  shortly  after  which  he  complained  of  chilliness,  some  nausea, 
and  headache.  After  these  symptoms  had  continued  about  an  hour,  his 
skin  became  extremely  hot,  the  pain  in  the  head  intense,  and  drowsi- 
ness was  complained  of,  which  soon  ended  in  perfect  coma,  with  deep 
snoring  and  insensibility ;  in  fact,  he  appeared  to  be  labouring  under  a 
violent  apoplectic  fit.  He  seemed  to  derive  much  advantage  from  bleed- 
ing and  other  remedies,  and  to  my  surprise  was  perfectly  well  when  I 
visited  him  in  the  evening.  The  day  but  one  after,  at  the  same  hour, 
the  very  same  symptoms  returned,  and  were  removed  by  the  same  re- 
medies.  I  must  confess  that  I  could  not  explain,  in  a  satisfactory  man- 


INTEHMITTEKT   FEVER.  359 

iier^  tlie  perfect  freedom  from  all  cerebral  and  paralytic  symptoms,  after 
two  such  violent  attacks  of  apoplexy ;  but  when  a  third  attack  came  on, 
I  then  saw  that  it  was  a  case  of  the  tertiana  soporosa  of  nosologists, 
and  I  prevented  the  return  of  the  fits  by  the  immediate  exhibition  of 
large  doses  of  sulphate  of  cjuina. 

Let  me  now  direct  your  attention  to  the  case  of  a  sailor  who  has  re- 
cently been  discharged.  This  boy  was  one  of  the  crew  of  a  vessel 
Mdiich  returned  lately  from  the  West  Indies,  and  was  exposed  to  great 
hardship  during  his  voyage.  Boys  in  his  situation  suffer  a  great  deal 
of  fatigue  and  rough  treatment ;  they  are  the  drudges  of  all  on  board, 
and  it  is  impossible  to  conceive  what  privations  they  endure.  When 
the  vessels  arrive  in  unhealthy  climates  they  are  generally  the  first  who 
fall  victims  to  the  prevailing  malady,  and  such  was  the  case  with  this  lad, 
w4io  got  yellow  fever  immediately  after  his  arrival  at  the  West  Indies. 
From  tliis  he  recovered,  but  on  his  way  home  was  attacked  with  irregu- 
lar intermittent,  which  lasted  for  a  considerable  time.  He  had  no  treat- 
ment, and  the  disease  subsided  spontaneously,  leaving  him  extremely 
weak  and  emaciated.  He  was,  however,  obliged  to  work  as  usual  on 
his  passage,  and  he  arrived  in  Dublin  about  three  wrecks  since,  debili- 
tated, thin,  and  with  a  countenance  expressive  of  long  continued  suffer- 
ing. He  had  on  his  admission  that  peculiar  hue  of  skin  which  often 
follows  tedious  intermittents,  and  which  those  who  have  once  seen  will 
always  recognise  with  facility.  This  colour  is  to  be  distinguished  from 
the  hue  of  light  jaundice — it  is  what  has  been  termed  a  clay  colour. 
In  the  present  instance  it  was  mixed  with  a  faint  tinge  of  jaundice,  and 
on  examining  the  stools  we  found  that  they  contained  scarcely  any  bile. 
He  had  no  fever;  his  pulse  was  rather  slow  and  regular;  he  complained  of 
lassitude ;  his  urine  was  deeply  tinged  with  bile ;  and  his  belly  tume- 
fied. On  examining  him,  we  found  that  the  abdominal  tumefaction  did 
not  depend  on  the  presence  of  fluid  in  the  peritoneum  :  it  was  produced  by 
enlargement  of  the  liver  and  spleen,  intestinal  congestion,  and  tympanitis. 

Here  was  a  case  of  what  has  been  vulgarly  termed  ague  cake ;  that 
species  of  congestion  and  enlargement  of  the  liver  and  spleen  which  is 
apt  to  accompany  the  paroxysms  of  an  intennittent,  and  in  some  cases 
to  remain  after  the  disease  has  subsided.  You  are  aware  that  some 
persons,  during  the  paroxysm  of  an  intermittent,  complain  of  pain  in 
tlie  right  hypochondrium,  but  more  frequently  in  the  left,  and  on  exami- 
nation the  liver  or  spleen  is  found  increased  in  size.  If  you  take  the 
trouble  of  reading  the  experiments  wliich  have  been  made  with  the  view 
of  illustrating  the  f  auctions  of  the  liver  and  spleen,  you  will  have  a  good 
idea  of  the  facility  with  which  enlargement  of  these  organs,  but  particu- 
larly of  the  latter,  inay  take  place. 


360  CLINICAL   MEDICINE. 

The  spleen  undergoes  very  remarkable  changes,  even  in  its  natural 
state,  during  the  process  of  digestion,  and  there  is  a  great  difference 
between  its  size  when  an  animal  is  fasting,  and  its  size  when  an  animal 
has  taken  food.  Indeed,  it  is  surprising  how  rapidly  it  will  become 
filled  with  blood,  and  how  quick  the  transition  is  from  a  state  of  col- 
lapse to  a  state  of  congestion.  It  is  easy,  therefore,  to  conceive  how 
the  spleen  may,  during  the  paroxysms  of  an  intermittent,  particularly 
in  the  cold  or  congestive  stage,  become  manifestly  enlarged.  The  in- 
crease of  size,  however,  never  occurs  to  such  an  extent  in  the  liver,  un- 
like the  spleen,  its  magnitude  remains  nearly  the  same,  and  its  volume 
does  not  vary  like  that  of  the  spleen  with  the  time  of  day  or  the  period 
of  digestion.  It  is  obvious,  therefore,  a  priori,  that  the  spleen  should 
be  more  frequently  the  seat  of  congestion  than  the  liver,  and  that  its 
enlargement  should  be  more  distinct  and  palpable. 

But  it  is  not  in  the  liver  or  spleen  alone  that  any  congestion  occurs 
during  an  aguish  paroxysm,  it  may  take  place  in  any  organ;  and  this, 
in  a  practical  point  of  view,  is  worthy  of  being  borne  in  mind.  Thus, 
in  a  case  which  I  attended,  the  patient  got  intermittent  of  a  tertian  type ; 
during  each  paroxysm  he  had  some  distress  about  the  chest  and  slight 
cough,  but  these  symptoms  disappeared  during  the  intervals.  As  the 
disease,  however,  went  on,  the  fits  of  coughing  and  dyspnoea  increased, 
and  the  sulphate  of  quina  failed  in  arresting  the  paroxysms.  The  pul- 
monary congestion  became  gradually  more  marked  and  permanent,  and 
no  longer  disappeared  during  the  intervals ;  finally,  inflammation  of  the 
lungs  took  place,  and  the  patient  died  with  extensive  hepatisation.  Tliis 
happened  several  years  ago,  when  the  old  notion  of  connecting  the 
cold  stage  of  ague  with  debility  was  universally  prevalent,  and  before 
the  practice  of  bleeding  for  the  relief  of  visceral  engorgement  had  been 
introduced.  Subsequently,  the  practice  of  bleeding  in  the  cold  stage,  as 
introduced  by  Dr.  Mackintosh,  was  tried  on  an  extensive  scale  in  the 
Meath  Hospital,  and  it  is  a  practice  which  I  can  strongly  recommend  in 
those  cases  where  there  is  recurring  inflammation  of  some  internal  organ. 
It  is  not  a  mode  of  treatment  applicable  to  all  cases,  and  in  mild  cases 
unaccompanied  by  extensive  congestion  of  any  viscus,  it  is  totally  unne- 
cessary ;  but  where  an  important  organ  is  threatened,  it  is  a  valuable 
remedy,  and  has  on  some  occasions  cut  short  the  paroxysms  altogether, 
or  rejidered  them  much  milder  and  more  manageable. 

Sometimes  ague  is  accompanied  by  symptoms  of  congestion  and  in- 
flammation of  some  internal  organ  during  the  paroxysms ;  and  yet,  by 
giving  sulphate  of  quina,  you  will  succeed  in  arresting  the  intermittent 
and  the  visceral  disease  at  the  same  time.  I  recollect  the  case  of  a  boy 
who  was  under  treatment  here  for  ague,  and  who,  during  the  paroxysms. 


INTERMITTET4T    FEVER.  361 

had  severe  bronchitis  with  dyspnoea.  The  cough  did  not  leave  him  even 
during  the  intervals,  but  it  was  much  milder ;  I  was,  however,  doubtful 
whether  the  case  would  admit  of  the  exhibition  of  sulphate  of  quina, 
from  the  violence  of  the  pulmonary  symptoms  during  the  fits.  I  deter- 
mined, after  some  time,  to  try  the  quina,  and  I  found  that  it  stopped 
both  the  intermittent  and  the  bronchitis.  It  is  to  be  observed,  however, 
that  in  this  case  the  bronchitis  was  of  a  chronic  character ;  and  I  believe 
that  in  all  cases  of  ague  accompanied  by  visceral  derangement,  where 
quina  succeeds  in  curing  the  disease,  the  inflammation  is  either  of  a 
trifling  description,  or  is  one  of  a  chronic  nature.  Where  the  visceral 
derangement  is  great,  quina  will  not  succeed,  and  hence  it  is  of  great 
importance,  in  the  treatment  of  ague,  that  you  should  carefully  attend  to 
the  state  of  the  internal  organs. 

There  are  several  forms  of  disease  which  simulate  intermittent  in  a 
very  remarkable  manner ;  and,  as  this  may  lead  to  very  dangerous  errors, 
it  is  necessary  on  all  occasions  to  make  a  strict  inquiry  into  the  origin 
and  history  of  the  complaint.  Some  forms  of  hectic  assume  the  inter- 
mittent character,  and  have  been  frequently  mistaken  for  ordinary  ague. 
Of  this  I  had  lately  a  very  striking  instance  in  the  case  of  a  lady,  who 
came  from  the  county  of  Limerick  to  consult  me  for  what  was  stated  to 
be  an  attack  of  irregular  intermittent.  She  had  been  confined  in  August ; 
had  been  feverish  after  her  accouchement — the  consequence,  she  believed, 
of  exposure  to  cold — and  got  a  slight  cough.  This  continued,  but  with- 
out any  expectoration,  for  two  or  three  weeks,  and  then  she  was  attacked 
with  fever  of  an  intermittent  character,  and  exhibiting  a  well-marked 
tertian  type.  She  began  to  take  quina,  but  this  aggravated  the  cough 
very  much  without  having  any  effect  on  the  paroxysms.  Yarious  other 
remedies  were  also  tried,  but  their  only  eflTect  was  to  render  the  paroxysms 
more  frequent  and  irregular.  The  moment  I  saw  her  I  was  convinced 
that  she  was  labouring  under  some  visceral  disease.  I  examined  her 
chest,  and  found  dulness  under  the  right  clavicle  with  tubercular  crepitus. 
Her  cough  had  been  dry  until  she  came  to  Dublin,  but  now  it  became 
suddenly  moist,  and  a  distinct  gargouillement  could  be  heard.  The  ap- 
parent intermittent  was  nothing  more  than  phthisical  hectic ;  and  Dr. 
Stokes,  who  was  called  in,  came  to  the  same  conclusion.  I  recollect 
having  observed  something  of  the  same  kind  in  a  case  which  I  attended 
some  time  ago  with  Sir  Henry  Marsh.  The  patient  had  well-marked 
intermittent,  and  we  treated  him  for  it ;  but  the  sulphate  of  quina,  and 
the  other  remedies  which  we  employed,  had  oidy  the  efi'ect  of  converting 
the  fever  into  remittent.  On  a  sudden,  the  gentleman,  without  having 
made  any  complaint  in  the  side,  or  any  thing  indicative  of  derangement 
of  the  liver,  became  suddenly  jaundiced,  and  sank  rapidly.  On  dissection, 


i 


362  CLINICAL  MEDICINE. 

we  found  seventeen  or  eighteen  small  circumscribed  abscesses  in  tlie 
substance  of  the  liver.  The  intermittent  hectic  here  depended  on  inter- 
stitial inflammation  of  the  liver — a  disease  which  is  generally  of  a  latent 
and  incurable  character. 

I  need  not  refer  here  to  certain  forms  of  fever  wltich  accompany  dis- 
ease of  the  brain  and  of  the  urinary  system,  and  which  are  remarkable 
for  their  intermittent  character.  There  is,  however,  one  form  of  ano- 
malous intermittent,  of  which  it  may  be  necessary  to  say  something : 
I  allude  to  that  species  of  ague  which  seems  to  be  exclusively  confined 
to  females  of  a  nervous  habit — at  least  I  have  never  met  with  it  in  any 
others.  Persons  of  tliis  description,  after  an  accouchement,  or  some 
acute  disease,  or  in  consequence  of  violent  mental  emotions,  will  some- 
times get  into  a  peculiar  state  of  health,  in  which  they  are  liable  to 
recurring  periodic  attacks  of  fever.  Some  time  since.  Dr.  Stokes  called 
me  to  see  a  lady  w^ho,  shortly  after  her  confinement,  had  got  an  attack 
of  well  marked  tertian.  She  had,  at  the  regular  time,  severe  rigors, 
followed  by  acceleration  of  pulse,  heat  of  skin,  and  profuse  sweating. 
"When  the  paroxysm  was  over,  she  felt  tolerably  well,  but  still  there 
was  much  excitement  of  pulse,  and  the  intermissions  were  anything 
but  perfect.  Sulphate  of  quina  had  been  tried  by  the  accoucheur  in 
attendance,  but  had  failed.  On  examining  the  case,  I  found  that  the 
lady  was  of  a  decidedly  nervous  and  hysteric  habit,  and  advised  the  use 
of  nervous  and  anti-spasmodic  medicines.  A  mixture  containing  musk, 
camphor,  and  ammoniated  tincture  of  valerian,  was  prescribed,  and  the 
intermittent  symptoms  rapidly  disappeared. 

But  to  return  to  the  case  of  this  boy.  How  are  we  to  treat  this  ague 
cake?  The  disease  has  not  as  yet  proceeded  so  far  as  to  produce 
ascites ;  but  if  permitted  to  run  on,  it  would  soon  cause  effusion  into 
the  peritoneal  cavity.  In  a  case  of  this  kind  a  great  deal  will  depend 
on  whether  there  is  any  fever  present  or  not.  If  there  is  no  remarkable 
excitement  of  pulse  or  heat  of  skin,  general  antiphlogistic  means  will  be 
unnecessary,  for  any  local  tenderness  or  irritation  can  be  relieved  by  local 
bleeding.  In  the  case  before  us,  there  was  a  slight  degree  of  tenderness, 
and  we  applied  leeches  once  with  benefit ;  but  we  did  not  apply  them 
over  the  abdomen — they  were  apphed  to  the  anus,  because  it  is  well 
known  that  leeches  applied  in  this  situation  have  a  remarkably  good 
effect  in  removing  intestinal  congestion,  and  consequently  in  reheving 
hepatic  engorgement.  Those  who  have  remarked  the  relief  which  a  flow 
of  blood  from  piles  gives  in  cases  of  hepatic  engorgement  with  dyspepsia, 
will  recognise  the  value  of  depletion  of  this  kind,  and  will  hnitate  the 
natural  mode  of  relief,  by  art.  Hence,  the  use  of  leeches  applied  to  the 
anus  in  cases  of  intestinal  congestion  and  hepatic  or  splenic  engorge- 


,  INTERMITTENT   FEVER.  363 

ment.  There  is  no  necessity  here  for  applying  a  great  number  of 
leeches — three  or  four  every  second  day  will  be  quite  sufficient,  and  we 
have  found  this  number  answer  every  necessary  purpose.  In  addition 
to  local  bleeding  and  attention  to  diet,  I  ordered  this  lad  to  take  a  few 
grains  of  blue  pill  once  a  day,  not  with  the  intention  of  affecting  his 
system,  but  merely  with  the  view  of  keeping  up  the  free  action  of  the 
bowels.  I  continued  the  mercury  only  as  long  as  the  tenderness  of  the 
liver  remained ;  for  experience  has  shown,  that  in  those  cases  of  ague 
cake  where  there  is  merely  enlargement  of  the  liver  without  tenderness, 
mercury  is  a  bad  remedy. 

In  cases  of  this  kind,  where  the  stage  of  active  congestion  is  past — 
where  there  is  no  fever — where  the  tenderness  is  removed,  and  nothing 
but  the  increased  size  of  the  liver  remains — how  are  you  to  accomplish 
a  cure  ?  Tirst,  by  inserting  one  or  two  setons  over  the  liver ;  and  se- 
condly, by  the  use  of  iodine  and  tonics.  The  use  of  setons  in  cases  of 
this  description  is  well  known,  and  needs  no  comment.  I  recollect  the 
case  of  a  lady,  who,  after  several  attacks  of  jaundice,  got  chronic  en- 
largement of  the  liver.  The  right  lobe  of  the  liver,  which  was  the 
portion  chiefly  affected,  extended  down  towards  the  crest  of  the  ilium, 
and  was  excessively  indurated.  This  state  had  occurred  after  the  pa- 
tient had  used  mercury  and  had  been  copiously  salivated.  Two  setons 
were  inserted  over  the  region  of  the  liver,  and  these  produced  rapid 
diminution  of  the  enlargement,  and  a  perfect  cure. 

With  respect  to  tonics,  I  may  observe,  that  they  prove  extremely  use- 
ful in  chronic  enlargement  of  the  liver  and  spleen.  We  are  in  the  habit 
of  using,  in  this  hospital,  a  combination  somewhat  similar  to  the  cele- 
brated Bengal  spleen  powder ;  it  consists  of  vegetable  and  mineral 
tonics,  combined  with  a  vegetable  purgative — as,  for  instance,  aloes — 
and  we  have  seen  the  best  results  from  its  use.  With  respect  to 
iodine,  it  is  a  valuable  adjuvant  in  such  cases,  particularly  where 
the  system  has  been  much  deranged,  and  where  mercury  would  be 
likely  to  run  down  the  patient.  Here  iodine  gives  vigour  to  the 
constitution,  and  tends  in  a  very  remarkable  manner  to  promote  the 
absorption  of  the  morbid  products,  on  which  the  enlargement  chiefly 
depends. 

Before  concluding  this  lecture,  I  wish  to  bring  before  you  some  sin- 
gular facts  respecting  the  liability  of  the  human  race  to  be  affected  with 
disease.  You  are  aware  that  certain  affections  are  peculiar  to  warm 
cHmates,  and  that  these  affections  prove  to  an  extraordinary  degree 
fatal  to  whites  who  may  come  within  the  operation  of  the  causes  by 
which  they  are  produced.  These  causes,  more  especially  as  regards 
Africa,  are  generally  believed  to  be  of  malarious  origin  ;  just  such 


864  CLINICAL  MEDICINE. 

causes  as  in  colder  climates  give  rise  to  agues^  but  in  the  torrid  zone 
produce  a  fatal  form,  not  of  intermittent,  but  of  remittent  fever. 
How  comes  it  to  pass,  however,  that  this  peculiar  form  of  fever  is 
almost  exclusively  confined  to  Africa,  occurring  on  both  its  western 
and  eastern  coasts,  while  it  is  not  met  with  off  the  shores  of  South 
America,  where  the  same  physical  causes,  so  far  as  relate  to  large 
swamps,  with  quantities  of  decaying  vegetable  and  animal  matters,  appa- 
rently exist  ?  Again,  in  the  published  accounts  of  the  recent  expedi- 
tions to  Borneo,  (I  especially  allude  to  those  of  Captain  Keppel,  in  the 
Dido,  and  of  Sir  Edward  Belcher,  in  the  Samarang),  we  hear  nothing 
of  the  crew  being  attacked  with  tliis  fever,  although  they  were  con- 
stantly exposed  to  malarious  emanations  in  rivers  with  swampy  banks, 
lined  with  mangroves,  in  which  there  were  low  tides,  and  in  the  self- 
same latitude  as  Cape  Coast. 

Let  us  also,  for  a  few  moments,  contrast  the  unhealthy  condition  of 
intertropical  Africa  with  other  portions  of  the  same  continent.  When  I 
come  to  speak  of  the  pernicious  effects  of  the  western  coast  on  our  sailors, 
I  shall,  in  the  case  of  the  Eclair  steamer,  give  you  a  very  recent  illus- 
tration of  the  deadly  character  of  the  emanations  by  which  the  coast 
fever  is  supposed  to  be  originated.  I  need  scarcely  say  that  the  same 
effect  is  produced,  if  possible,  in  a  tenfold  degree  amongst  the  white 
dwellers  on  land  in  this  unhealthy  region ;  but  I  cannot  forbear  read- 
ing for  you  a  single  sentence  from  Bathurst,  on  the  mortality  of  one  of 
our  settlements.  "In  1824,  there  were  346  European  soldiers  at 
Sierra  Leone,  of  these  301  died  in  the  rains;  and  in  1825,  of  1193, 
there  died  621 ;  and  of  108  young  men  sent  to  the  Isles  de  Los,  to 
the  north  of  the  colony,  62  died.''  This  deadly  character  of  the  cli- 
mate, moreover,  affects  the  inferior  classes  of  animals  as  well  as  man. 
In  Travels  in  Western  Africa  in  1845-6,  by  John  Duncan,  it  is  stated, 
that  at  Cape  Coast  Castle  agriculture  has  made  httle  progress,  probably 
owing  to  the  want  of  horses,  which  cannot  live  more  than  a  few  weeks  ; 
but  the  native  breed  of  cattle  is  very  handsome,  though  small,  and  is 
not  subject  to  disease. 

Now  there  is,  probably,  not  a  more  salubrious  climate  in  the  whole 
world  than  Southern  Africa.  All  writers  on  the  recent  Kaffu*  war 
agree  that  one  of  its  most  remarkable  features  was,  the  general  good 
health  of  the  troops,  notwithstanding  the  great  exertions  and  hardsliips 
to  which  they  were  exposed.  And  in  a  very  interesting  paper  recently 
published  by  Colonel  Napier,  entitled,  "A  few  Months  in  Southern^ 
Africa,''  I  find  the  following  singular  and  interesting  observations : 
"The  most  sudden  transitions  from  heat  to  cold,  and  vice  versd^  is 
a  marked  peculiarity  of  this  changeful,  though,  strange  to  say,  mosti 


MALARIOUS   FEVER   OF    AFRICA.  365 

salubrious  climate,  in  which  one  may,  generally  speaking,  and  with 
equal  impunity,  sleep  under  the  bush  at  the  mercy  of  dew  and  rain, 
or  expose  oneself  during  all  hours  of  the  day  to  the  fiery  heat  of  a 
vertical  sun.  On  the  present  occasion,  a  most  grilhng  hot  day  was 
succeeded  by  a  night  as  bitterly  cold ;  and  yet  our  bivouack  produced 
no  bad  consequences.'^ 

Again,  let  us  take  the  Island  of  Ascension,  off  the  coast  of  Western 
Africa,  and  we  find  that  at  the  time  of  Alexander's  visit,  as  narrated 
in  his  "  Western  Africa,''  all  the  Europeans  and  Africans  were  in  the 
strongest  health,  and  the  former  had  florid  complexions — a  most  un- 
usual circumstance  within  seven  degrees  of  the  line.  There  were  60 
Europeans  and  40  Africans ;  the  former  suffered  no  inconvenience  in 
labouring  in  the  sun  for  seven  or  eight  hours  all  the  year  round,  resting 
in  the  middle  of  the  day. 

In  connexion  with  this  subject,  I  cannot  forbear  reading  for  you  the 
following  remarks  by  Mr.  Bynoe,  on  the  climate  of  Northern  Aus- 
tralia ;  they  are  from  the  second  volume  of  "  Discoveries  in  Austraha," 
by  J.  L.  Stokes.  "  I  find,  on  a  reference  to  the  Medical  Journals,  as 
well  as  to  a  Meteorological  table  kept  by  me  during  a  period  of  sixty 
years,  on  the  coast  of  Australia,  and  under  every  variety  of  climate, 
that  we  had  no  diseases  peculiar  to  that  continent,  and  I  am  led  to  be- 
lieve it  a  remarkably  healthy  country.  On  the  north  and  north-west 
coasts,  where  you  will  find  every  bight  and  indentation  of  land  fringed 
with  mangroves,  bordering  mud-flats,  and  ledges  formed  by  coraUines 
in  every  stage  of  decomposition,  with  a  high  temperature,  no  fevers  or 
dysenteries  were  engendered.  Our  ship's  company  were  constantly  ex- 
posed in  boats  to  all  the  vicissitudes  from  wet  to  dry  weather,  sleeping 
in  mangrove  creeks  for  many  months  in  succession,  pestered  by  mus- 
quitos  during  the  hours  of  repose ;  yet  they  still  remained  very  healthy, 
and  the  only  instance  where  the  climate  was  at  all  prejudicial  (if  such  a 
term  can  be  applied),  was  in  Victoria  river,  on  the  north  coast,  where 
the  heat  was  at  one  period  very  great,  and  the  unavoidable  exposure 
caused  two  of  the  crew  to  be  attacked  with  coujp  de  soleil.  Our  casu- 
alties consisted  of  two  deaths,  during  our  stay  on  the  Australian  coast ; 
one  from  old  age,  and  the  other  a  case  of  dysentery,  contracted  at 
Coepang." 

But  to  return ;  how,  I  say,  can  we  account  for  such  pecuHarity  in 
the  climate  of  intertropical  Africa  ?  That  it  does  exist  there  can  be  no 
doubt,  although  the  fact  has  not,  as  far  as  I  am  aware,  been  hitherto 
noticed.  It  must  depend  on  some  chemical  or  physical  cause,  as  yet 
undiscovered. 

In  the  absence  of  any  positive  knowledge  on  this  subject,  are  there 


866  CLINICAL   MEDICINE. 

any  means  by  whicli  the  almost  uniform  fatality  of  the  African  fever 
may  be  rendered  less  destructive  to  mankind  ?  The  only  efficient  me- 
thod for  so  doing,  I  beheve,  must  be  sought  for  by  an  investigation 
into  the  effects  of  climate  on  the  human  race. 

It  is  a  remarkable  and  curious  fact,  that  man  is  the  only  animal  in 
whom  the  identity  of  species  is  preserved,  while  the  varieties  of  his  phy- 
sical constitution  are  so  great,  that  he  is  enabled,  aided  by  the  resources 
reason  and  experience  suggest,  to  inhabit  every  latitude,  and  multiply  in 
every  climate ;  but  hitherto  he  has  seemed  unconscious  of  the  value  of 
the  gift  thus  bestowed  by  the  hand  of  Nature — and,  while  history  re- 
cords the  sad  effects  of  war  in  diminishing  or  destroying  these  varieties 
of  the  human  species,  we  search  its  pages  in  vain  for  any  attempt  to 
preserve  or  increase  them ;  and  yet  there  can  be  little  doubt  that  a 
proper  attention  to  their  physical  and  mental  qualities  would  soon  make 
known  what  region  of  the  earth  each  is  peculiarly  fitted  to  inhabit,  and 
what  duties  calculated  to  perform  in  extending  the  empire  of  civilisa- 
tion. Let,  then,  the  rulers  of  nations  arrest  the  hand  of  destruction — 
let  us  have  no  longer  to  contemplate  such  catastrophes  as  the  annihila- 
tion of  the  aboriginal  inhabitants  of  Yan  Dieman's  Land,  and  let  the 
voice  of  reason  (not  to  invoke  the  holy  name  of  rehgion)  stay  the  struc- 
ture of  the  funeral  pile,  on  which  may  soon  be  placed  the  bfeless  corpse 
of  that  noble  member  of  the  human  family,  the  North  American 
Indian. 

It  has  been  long  known,  that  negroes  can  withstand  the  action  of  de- 
leterious exhalations  that  are  fatal  to  Europeans.  A  striking  instance 
of  this  kind  must  be  fresh  in  the  memories  of  all.  In  the  expedition  to 
the  Niger,  undertaken  by  command  of  the  government  in  1841  and  1842, 
the  mortality  from  fever  was  so  great  as  entirely  to  prevent  the  execu- 
tion of  the  intended  design,  and  one  of  the  iron  steamers  was  saved  only 
by  the  exertions  of  the  surgeon,  who  acted  as  engineer,  nearly  aU  the 
other  whites  on  board  having  perished.  Three  steamers  were  employed 
in  this  unfortunate  enterprise,  and  their  united  crews  consisted  of  145 
white  men,  and  158  blacks;  of  the  former,  130  were  attacked  with 
fever  in  the  Niger,  and  40  perished ;  while  of  the  blacks  only  eleven 
caught  fever,  and  in  them  the  disease  assumed  a  comparatively  mild 
form,  and  none  died.  Of  the  blacks,  133  were  entered  on  the  coast  of 
Africa,  and  consisted  of  native  Africans,  chiefly  Kroomen,  a  littoral  and 
seafaring  tribe,  whose  intelligence,  nautical  skill,  and  fidelity,  will  hereafter 
render  them  most  available  in  the  hands  of  some  other  civilised  nations. 
Of  the  133  natives,  the  greater  number  had  never  been  on  the  waters 
of  the  Niger  before,  and  yet  not  one  of  them  sickened ;  the  remaining 
25  blacks  were  entered  in  England,  and  consisted  of  men — some  natives 


MALARIOUS    FEVEll    01'    AFRICA.  3G7 

of  the  West  Indies,  some  of  the  United  States  of  America,  and  one  or 
two  from  Nova  Scotia ;  of  these,  eleven,  as  I  before  mentioned,  con- 
tracted fever,  and  none  died,  although  every  one  of  them  had  been  in 
England,  and  absent  for  several  years  from  tropical  climates.  This  fact. 
Dr.  M'William  observes,  proves  "  that  the  immunity  from  fever  in  warm 
countries,  which  »is  enjoyed  by  the  dark  races,  is  to  a  certain  extent,  de- 
stroyed by  a  temporary  residence  in  another  climate.''^  This  is  quite 
true,  but  let  us  consider  it  in  another  point  of  view.  Ten  of  the  25 
blacks  entered  in  England  were  West  Indians,  and  had  never  visited 
the  Niger,  and  yet  they  either  escaped  altogether,  or  had  but  slight 
fever ;  and  two  of  the  twenty-five  were  born  in  cold  climates.  It  ap- 
pears, therefore,  that  the  black  man  has  a  physical  conformation  which 
fits  him  to  resist  better  than  the  white  the  deleterious  fever  of  tropical 
climates. 

The  same  fact  is  still  more  strongly  proved  by  the  unfortunate  results 
of  the  fever  with  which  the  crew  of  the  Eclair  steamer  were  attacked, 
when  stationed  on  the  coast  of  Africa  in  1 845.  I  need  not  enter  into 
any  particular  account  of  these  circumstances,  so  well  known  to  all ; 
it  is  sufficient  for  my  present  purpose  to  state  that,  as  appears  from  the 
official  documents,  out  of  forty  Kroomen  on  board,  not  a  single  indi- 
vidual was  attacked  with  the  fever  which  proved  so  fatal  to  nearly  every 
European  on  board,  until  after  the  vessel  arrived  in  England,  when 
five  slight  fever  cases  occurred  amongst  them,  but  which  are  ascribed 
by  Sir  William  Burnett  to  their  being  sent  on  board  the  "  Worcester," 
a  much  colder  ship  than  their  own. 

Again  it  is  stated  by  Major  Forbes,  in  his  account  of  an  eleven  years' 
residence  in  Ceylon,  that  when  the  English  were  occupied  in  construct- 
ing the  splendid  roads  which  now  traverse  that  island,  some  of  the  lo- 
cahties  were  found  so  destructive  of  human  life,  that  even  the  native 
Cingalese  labourers  fell  victims  to  disease  in  great  numbers,  and  conse- 
quently the  undertaking  must  have  been  abandoned,  had  it  not  been 
found  that  our  Kaflir  soldiers,  who  acted  as  pioneers,  were  comparatively 
exempt  from  the  effects  of  the  noxious  exhalations,  and,  by  their  labours 
therefore,  the  work  was  perfected  in  places  where  heat  and  moisture, 
acting  on  the  accumulated  vegetable  deposit  of  this  extensive  wilderness 
of  wood,  gave  rise  to  a  miasma  fatal  to  the  other  races  employed  by  the 
government. 

In  a  lecture  which  I  delivered  before  the  College  of  Physicians,  in 
1844,  I  entered  at  length  into  the  history  of  the  different  races  of 
mankind,  as  regards  their  diffusion  over  the  face  of  the  globe,  and  for 
further  information  on  this  subject  I  must  refer  you  to  that  lecture, 
wliich  was  pubhshed  in  "  The  Dublin  Literary  Journal,"  of  April  1st, 


\ 


368  CLINICAL   MEDICINE. 

1844.  At  present,  wlien  speaking  of  ague,  I  thought  that  the  fore- 
going observations  would  prove  interesting,  as  bearing  on  the  malarious 
origin  of  disease  :  But  I  cannot  conclude  without  expressing  my  convic- 
tion, one  which  I  have  arrived  at  from  long  consideration  given  to  the 
subject,  that  the  several  original  races  of  mankind  were  created  by  the 
Almighty  power,  with  the  view  of  their  peculiar  adaptation  to  the  different 
climates  of  the  globe.  And  I  do  not  know  any  more  interesting  or 
more  benevolent  subject  of  inquiry  which  could  engage  your  minds,  than 
one  into  the  physical  circumstances  by  which  any  peculiar  variety  of  the 
human  race  is  constituted  for  inhabiting  an  individual  climate. 


369 


LECTURE  XXVI. 


ON   THE    LAW   WHICH    REGULATES    THE    RELAPSE-PERIODS    OF   AGUE. 

I  SHALL  devote  this  lecture  to  the  consideration  of  an  interesting  subject 
to  which  I  have  lately  paid  much  attention,  namely,  as  to  whether  there 
is  any  law  which  regulates  the  relapse  periods  of  ague. 

Having  noted  with  much  anxiety  and  accuracy  the  course  of  a 
quartan  ague  for  twenty-seven  months,  I  constructed  a  table  for  the 
purpose  of  obtaining  a  connected  view  of  the  number  and  dates  of  the 
fits.  This  table  had  been  made  for  some  time  before  I  discovered  that 
it  contained  data  which  authorize  us  in  concluding  that  the  law  regu- 
lating the  periodicity  of  agues  applies  not  only  to  the  succession  of 
paroxysms,  but  is  extended  to  the  free  intervals  between  them — in  other 
words,  that  the  same  law  of  periodicity  which  governs  the  disease  while 
it  occasions  fits,  continues  likewise  to  preside  over  its  latent  movements 
during  the  interval  when  no  fit  occurs,  and  thus  the  true  periodic  rate 
is  carried  on,  though  as  in  a  clock  from  which  the  striking  weight  has 
been  removed,  the  usual  signal  does  not  mark  the  termination  of  each 
certain  definite  portion  of  time. 

This  law,  now  for  the  first  time  brought  to  light,  exhibits  a  new 
example  of  the  tenacity  with  which  periodicity  clings  to  a  disease,  when 
once  firmly  impressed  on  it,  and  recalls  to  mind  a  very  similar  pheno- 
menon observed  with  respect  to  the  catamenia,  which,  having  been 
suppressed  for  many  months,  not  unfrequently  reappear  on  the  very  day 
on  which  the  monthly  period  would  have  occurred,  had  no  such  sup- 
pression taken  place. 

The  case  I  am  about  to  detail  possesses  likewise  several  features  of 
practical  interest,  and  serves  to  show,  that  a  very  obstinate  species  of 
ague,  accompanied  by  various  complications,  may  be  perfectly  cui-ed  by 
the  use  of  quina  alone ;  and  that  very  large  quantities  of  that  powerful 
medicine  may,  under  such  circumstances,  be  taken  not  only  with  im- 

VOL.  I.  24 


J370  CLINICAL   MEDICINE. 

punity  but  with  advantage.  A  boy  of  good  constitution  and  eleven 
years  of  age  had  been  at  a  boarding  school  in  Kent,  during  tlie  spring 
and  summer  of  1842,  and  remained  in  perfect  health  all  that  time. 
In  autumn  he  was  very  imprudently  allowed  to  bathe  daily  in  a  pond  of 
stagnant  water,  and  he  frequently  continued  in  the  water  for  more  than 
an  hour.  In  the  November  following,  feverish  symptoms  exhibited 
themselves,  and  he  was  several  times  an  inmate  of  the  school  infirmary  : 
his  disease  was  considered  to  be  a  frequent  return  of  feverish  attacks 
from  cold  and  indigestion ;  and  accordingly  he  was  treated  by  confine- 
ment and  low  diet,  with  mercurial  and  saline  purgatives.  Notwith- 
standing these  remedies,  the  disease  frequently  recurred,  nor  was  its 
true  nature  even  suspected  by  the  medical  attendant.  He  arrived  in 
Dublin  on  the  evening  of  the  16th  of  December,  1842,  and  the 
moment  I  saw  him  I  concluded,  from  the  peculiar  tinge  of  his  com- 
plexion, that  he  was  affected  with  ague.  He  had  a  slight  cough,  but 
in  other  respects  was  tolerably  well,  although  fatigued  by  his  journey  : 
he  slept  well  that  night.  On  the  17th  of  December  he  made  a  good 
breakfast  and  dinner,  but  after  dinner  he  sickened :  he  slept  well  during 
the  night,  and  awoke  at  eight  o'clock  on  the  morning  of  the  18th. 
He  was  hot  and  feverish  all  day  uptil  about  eight  o'clock  in  the  even- 
ing :  the  paroxysm  of  ague  thus  lasting  twenty-four  hours.  He  got 
at  4  P.M.  5  grains  of  sulphate  of  quina.  19th.  Slept  all  last  night, 
free  from  fever ;  sulphate  of  quina  repeated.  20th.  No  fever :  cough 
much  better ;  third  dose  of  quina.  21st.  He  slept  well  during  the 
night;  he  awoke  free  from  the  fever,  which  however  returned  at  11 
o'clock,  A.M. ;  the  fit  lasted  eight  hours.  The  quina  was  repeated. 
22nd.  The  dose  of  quina  was  increased  to  74  grains,  and  continued  for 
some  days.  There  was  no  return  of  the  fever  until  January  the  8th, 
on  which  day  he^  had  a  slight  fit.  We  here  remark  for  the  first  time^ 
that  the  paroxysm  occurred  on  the  very  day  on  which  it  would  have 
occurred  had  it  been  going  on  regularly  from  the  21st  of  December ; 
for  then  the  days  should  have  been  the  24th,  27th,  30th,  and  2nd,  5th, 
and  8th  of  January ;  in  other  words,  the  periodic  time  of  the  disease, 
while  it  exhibited  no  evident  paroxysm,  was  the  same  as  when  it  did. 
The  quina  was  resumed  on  the  8th  of  January,  and  7^  grains  of  it 
given  daily  for  four  days.  The  disease  now  disappeared  for  a  time,  but 
on  January  21st  he  had  a  slight  fit ;  and  it  is  to  be  remarked,  that 
this  does  not  correspond  with  the  day  upon  which  it  should  have  re- 
appeared, viz.  the  20th,  had  its  latent  periodic  time  remained  the  same, 
as  may  be  seen  in  the  table.  To  proceed  with  this  particular  part  of 
our  subject : — paroxysms  occurred  on  the  21st,  24th,  and  27th  of 
January,  and  then  ceased,  in  consequence  of  the  exhibition  of  quina. 


RELAPSE-PERIODS    OF   AGUE.  371 

until  the  10th  of  March.  Now  reference  to  the  table  will  show,  that 
had  the  disease  observed  the  quartan  period,  from  the  27th  of  January, 
it  would  have  reappeared  on  the  10th  of  March.  Pits  occurred  on  the 
13th  and  16th  of  March,  and  then  ceased,  under  the  influence  of  medi- 
cine, until  the  30th  of  April,  the  very  day  which  corresponds  with  the 
quartan  period  had  it  gone  on  regularly  from  the  16th  of  March,  as 
may  be  seen  by  reference  to  the  table.  The  fits  occurred  again  on  the 
8rd  and  6th  of  May,  and  were  then  arrested  by  the  use  of  quina, 
again  to  reappear  on  the  24th  of  May,  the  very  day  the  fit  was  due  : 
but  of  this  more  hereafter.  "We  have  seen  that  the  fit  of  the  21st  of 
January  was  slight,  and  that  on  the  24th  was  severe,  commencing  at 
three,  p.  m.  The  headache  was  very  bad  :  the  fever  continued,  more 
or  less,  to  the  25th,  and  his  appetite  was  not  restored  until  the  26th. 
On  the  27th,  about  three,  p.  m.,  another  fit,  much  less  severe  :  scarcely 
any  headache :  less  heat  of  skin,  nausea,  and  restlessness  :  passed  a 
good  night,  and  was  perfectly  well  at  breakfast  on  the  2Sth. 

From  the  18th  of  December  to  the  2nd  of  January,  he  took  75 
grains  of  quina;  from  the  8tli  to  the  12th,  30  grains ;  and  from  the 
21st  to  the  30th,  60  grains;  total  amount,  165  grains.  The  fit  did 
not  return  on  the  30th  of  January,  and  he  seemed  in  every  respect 
perfectly  well  on  that  day.  Medicine  was  now  discontinued.  He  had 
not  the  slightest  indication  of  disease  until  Eriday,  March  the  10th. 
The  fit  was  then,  however,  so  slight,  that  I  was  doubtful  concerning 
the  actual  occurrence  of  a  relapse,  and  therefore  did  not  resume  the 
quina,  until  a  very  severe  aguish  paroxysm  on  the  13th  of  March  re- 
moved all  doubt  upon  the  subject.  It  is  particularly  worthy  of  notice, 
that  the  boy  exhibited  not  the  slightest  feeling  or  precursory  symptom 
of  indisposition,  and  had  a  very  healthy  colour  up  to  the  very  beginning 
of  the  paroxysm  on  the  10th.  This  is  not  usual,  nor  did  it  often 
happen  in  the  case  before  us ;  for,  as  the  disease  became  more  deeply 
rooted,  the  return  of  the  fit  was  invariably  preceded,  for  a  few  days, 
by  an  unhealthy  aspect  and  a  pale  colour.  Still  the  sudden  manner  in 
which  the  ague  fit  sometimes  commenced  is  very  remarkable,  for  I  have 
seen  this  patient  sit  down  to  a  meal  with  a  good  appetite,  and  he  had 
scarcely  half-finished  when  all  at  once  he  felt  indisposed,  every  trace  of 
appetite  vanished,  and  the  aguish  rigor  set  in.  I  particularly  remarked 
too,  that  there  was  no  derangement  whatsoever  perceptible  in  his  sleep, 
urine,  alvine  evacuations,  tongue,  or  the  functions  of  any  other  organ, 
during  the  twenty-four  hours  that  preceded  the  relapse  of  the  10th  of 
March.  At  later  stages  of  the  complaint,  this  freedom  from  functional 
disturbance  before  the  actual  fit  was  not  so  clear,  but  on  the  contrary,  the 
boy  usually  felt  a  little  unwell  for  a  day  or  two  before  the  fit  commenced. 


372  CLINICAL   MEDICINE. 

These  facts  show  us  that  ague  is  at  first  purely  periodic,  the  health 
being  totally  unaffected  during  the  interval  between  the  attacks,  but  as 
the  disease  becomes  rooted,  as  I  have  said  before,  in  the  constitution,  the 
intervals  are  rendered  less  purely  healthy.  On  the  14th  of  March  he 
again  began  the  quina,  in  daily  doses  of  ten  grains.  The  fit  of  the  13th 
had  been  very  severe;  that  of  the  15th  was  milder,  and,  as  I  abeady 
stated,  the  ague  then  ceased,  not  to  reappear  until  April  the  30th.  From 
the  14th  of  March  until  the  1 7th  he  took  ten  grains  of  quina  daily,  and 
then  continued  the  medicine  in  gradually  decreasing  doses,  until  ninety 
grains  had  on  the  whole  been  taken  during  this  month.  The  paroxysm 
of  the  30th  of  April  was  slight  but  well  marked;  that  of  the  3rd  of 
May  was  sudden,  and  attended  from  its  commencement  with  raving  and 
hallucinations,  which  were  very  alarming,  and  lasted  for  two  hours, 
until  the  hot  fit  was  established.  This  fit  was  not  perfectly  solved 
sooner  than  sixteen  hours,  and  created  so  much  uneasiness  in  my  mind 
that  I  resolved,  contrary  to  my  previously  formed  resolution,  to  give  him 
quina  in  order  to  prevent  another  attack,  or  at  all  events  diminish  its 
violence,  fearing  that  the  disease,  if  unchecked,  might  pass  into  its  worst 
form,  the  apoplectic  or  fehris  intermittens  perniciosa.  Accordingly,  on 
the  4th,  5th,  and  6th  of  May  he  took  forty  grains  of  quina,  notwith- 
standing which  he  had  a  fit,  as  I  before  mentioned,  but  slight,  and  with- 
out any  cerebral  symptoms,  on  the  6th.  The  following  day  he  went, 
by  Dr.  Stokes'  advice,  to  reside  in  a  cottage  most  favourably  situated 
over  the  sea,  on  the  high  cliffs  of  the  south  side  of  the  hill  of  Howth ; 
and  on  the  9th  he  took,  at  2,  p.  m.,  a  draught  containing  ten  drops  of 
laudanum  and  twenty  of  sulphuric  ether.  He  spent  his  time  chiefly  in 
the  open  air,  and  his  appearance  became  much  more  healthy.  He  re- 
mained quite  free  from  the  disease,  was  active,  strong,  and  cheerful, 
with  an  excellent  appetite  and  good  spirits,  and  returned  to  Dublin  on 
the  23rd  day  of  May,  having  passed  seventeen  days  free  from  a  pa- 
roxysm. 

On  the  24th,  at  4  p.  m.,  he  had  a  shght  paroxysm,  and  on  the  27th, 
at  the  same  hour,  another,  which  was  well  marked  but  not  severe,  for 
he  slept  well  the  whole  night,  and,  though  he  had  but  httle  appetite 
next  morning,  he  was  in  every  other  respect  quite  well.  We  were  led, 
probably  erroneously,  to  attribute  the  comparative  mildness  of  this  fit  to 
a  draught  containing  camphor  mixed  with  sweet  spirits  of  nitre  and 
seven  drops  of  laudanum,  taken  at  1,  p.m.,  and  repeated  at  3,  p.m.,  the 
latter  followed  by  a  cup  of  hot  coffee.  On  the  28th  of  May  he  again 
went  to  Howth,  and  was  directed  to  take  an  opiate  draught  on  the  30tl 
as  before,  and  to  go  to  bed  at  three  o''clock,  and  by  means  of  hot  tea  io* 
try  to  prevent  the  fit.     Notwithstanding  these  measures  the  fit  came  on 


EELAPSE-PEKIODS    OE  AGUE.  373 

at  tlie  usual  liour_,  on  the  30tli  of  May,  and,  though  not  of  long  conti- 
nuance, was  severe,  and  its  commencement  was  accompanied  by  spectral 
illusions.  Dr.  Stokes  and  I  now  determined  to  lay  aside  medicine  and 
try  what  the  pure  air  of  Howth,  aided  by  fine  weather  and  constant  out- 
door amusement,  would  do.  The  event  did  not  justify  our  expectations, 
for- he  had  fits  on  the  2nd,  5th,  8th,  11th,  and  16th  of  June,  and  these 
fits  came  on  with  great  regularity  about  3,  p.m.,  some  of  them  slight  and 
interrupting  his  amusement  only  for  an  hour  or  two,  but  others  severe, 
and,  though  not  lasting  more  than  six  or  eight  hours,  yet  attended  with 
headache,  nausea,  vomiting,  and  purging,  wliich  affections  seemed  to 
relieve  the  head.  As  he  had  eight  successive  fits  and  the  disease  evinced 
no  inclination  to  subside  spontaneously,  we  resolved  again  to  try  the 
sulphate  of  quina,  and  on  the  15  th  gave  him  five  grains  twice,  on  the 
]6th  three  times,  and  on  the  17th  twice  before  10  o'clock,  in  order  to 
interrupt  the  fit;  on  the  18th  twice,  on  the  19th  three  times,  and  on 
the  20th  twice ;  so  that  he  took  seventy  grains  during  these  six  days. 
The  result  of  this  treatment  was  a  milder  fit  on  the  17th,  and  none  on 
the  20th.  Thus  the  plan  of  giving  no  quina  had  been  tried  from  the 
6th  of  May  to  the  15th  of  June,  and  it  is  observable  that  after  this  un- 
interrupted series  of  nine  fits,  the  seventy  grains  of  quina  which  were 
required  to  stop  the  fits  produced  only  an  interval  of  eleven  free  days, 
from  the  day  the  medicine  was  last  exhibited,  viz.  the  20th  of  June ;  for 
on  the  second  of  July  he  had  a  sHght  but  well-marked  shadow  of  a  fit, 
consisting  of  paleness,  collapse,  and  some  headache,  short  in  continuance, 
and  followed  by  a  scarcely  perceptible  hot  fit.  We  have  already  seen 
that  where  only  two  fits  had  been  allowed  to  occur,  forty  grains  produced 
a  free  interval  of  seventeen,  and  the  advantage  therefore  of  immediately 
giving  quina,  and  as  soon  as  possible  arresting  the  course  of  the  paroxysm, 
was  so  obvious,  that  on  the  evening  of  the  2nd  of  July  I  gave  him  five 
grains  of  quina,  and  twenty  grains  more  were  given  on  the  3rd,  4th,  and 
5th.  Now  the  good  effects  of  at  once  arresting  the  disease  in  its  pro- 
gress were  made  very  evident,  for  these  25  grains  obtained  a  clear  in- 
terval, without  fever  and  without  medicine,  of  fifteen  days. 

On  the  evening  of  the  20th  he  was  out  boating  at  Kingstown,  and 
came  home  chilled,  as  he  said,  by  the  breeze,  but  as  he  recovered  after 
tea,  and  slept  very  well  during  the  night,  we  flattered  ourselves  that  it 
was  merely  a  chill  and  not  the  shadow  of  an  ague  fit.  But  on  the  23rd 
he  had  a  decided  though  not  severe  fit.  He  now  recommenced  quina — 
five  grains  on  the  23rd,  five  on  the  24th,  ten  on  the  25th,  and  ten  on 
the  26th,  on  which  day  he  had  a  well-marked  fit,  but  not  of  long  con- 
tinuance, and  its  commencement  was  deferred  until  half-past  seven  in 
the  evening.     On  the  27  th  he  took  five  grains,  on  the  28th  ten  grains. 


374  CLINICAL   MEDICINE. 

and  on  the  29tli  ten  grains  :  on  that  day  he  had  no  fit :  so  that  between 
the  23rd  and  29th,  both  days  inclusive,  he  had  taken  fifty-five  grains, 
which  quantity  produced  a  free  interval  of  eleven  days.  This  result 
forms  a  striking  contrast  with  the  former,  and  proves  that  twenty-five 
grains  employed  immediately  on  the  appearance  of  the  first  fit  produces 
a  longer  interval  than  fifty-five  grains  employed  after  the  second  fit  had 
been  allowed  to  come  on.  I  now  determined  to  act  on  the  experience 
thus  gained,  and  give  the  medicine  the  moment  the  disease  reappeared. 
This  it  did  on  the  10th  of  August,  when  he  had  a  decided  fit,  which 
commenced  at  half-past  five,  and  seemed  to  have  gone  off  before  nine 
o'clock,  for  he  slept  perfectly  well,  and  was  free  from  fever  during  the 
night. 

In  this  case  the  first  paroxysm  of  some  of  the  series  was  of  long 
continuance,  and  embraced  portions  of  two  successive  days,  so  as  to 
make  it  difficult  to  determine  the  exact  date  of  the  paroxysm.  Thus 
in  December,  1842,  the  ague  fit  commenced  on  the  17th,  in  the  after- 
noon, and  lasted  for  twenty-four  hours,  that  is,  until  seven  o'clock  on 
the  evening  of  the  18th.  If  we  date  it  from  the  commencement  of 
this  paroxysm,  that  is  the  17th,  the  next  fit  should  have  been  on  the 
20 til,  whereas  it  actually  occurred  on  the  21st  December,  here  then  the 
date  must  be  taken  from  the  day  on  which  the  fit  terminated.  An 
example  of  the  contrary  nature  occurred  on  the  9th  of  March,  1844, 
after  a  free  interval  of  nearly  five  months,  when  a  paroxysm  of  eighteen 
hours'  duration  partly  occupied  the  9th  and  partly  the  10th  of  March. 
In  this  instance  the  two  fits  next  in  order  were  prevented^  but  as  one 
occurred  on  the  18th  of  March  it  is  clear  that  the  date  must  be  taken 
from  the  day  on  which  the  fit  hegan,  not  from  that  on  which  it  ended. 
These  two  facts,  apparently  contradictory,  taken  in  conjunction  with 
others  of  a  similar  nature  observed  in  this  case,  prove  that  when  ague 
commences  or  reappears  after  a  long  cessation,  it  is  not  always  easy  at 
first  to  determine  accurately  the  dates  of  the  fits. 

He  took  five  grains  of  quina  on  the  10th  of  August,  ten  on  the  11th, 
ten  on  the  12th,  and  five  on  the  13th,  on  which  day  he  had  no  fit. 
It  was  now  remembered  that  on  the  8th  and  9th  of  August  some  pre- 
cursory symptoms  had  appeared,  denoting  the  approach  of  the  fit,  for 
on  those  days  he  complained  of  considerable  vertigo  in  the  morning 
after  breakfast,  particularly  on  going  to  stool.  The  giddiness  was  very 
bad  on  the  morning  of  the  11th,  but  was  much  diminished  on  the  12th. 
Notwithstanding  this  giddiness  he  continued  the  quina,  and  the  vertigo 
with  its  accompanying  paleness  and  sHght  nausea,  disappeared.  It  was 
now  proved  that  the  occurrence  of  the  morning  vertigo  might  serve  to 
give  us  one  or  two  days'  warning  of  the  future  fit,  and  accordingly  it 


RELAPSE-PERIODS   OF   AGUE.  375 

was  determined  to  resume  the  medicine  the  moment  he  complained  of 
this  vertigo,  which  he  did  very  much  when  at  stool  after  breakfast  on 
the  21st  of  August.  He  took  five  grains  at  mid-day,  and  five  before 
breakfast  on  the  22nd.  The  giddiness  was  much  less.  On  the  23rd 
he  took  five  grains  in  the  morning,  and  had  no  vertigo  after  breakfast, 
and  on  the  24th  five  grains  more  were  taken,  and  then,  as  he  appeared 
quite  well,  the  medicine  was  discontinued,  but  was  again  resumed  on 
the  31st  of  August,  as  he  complained  of  some  vertigo,  and  he  took 
five  grains  daily  until  the  8th  of  September,  when  he  was  quite  free 
from  ague. 

At  this  period  of  his  treatment  I  was  not  aware  of  the  law  which  go- 
verns the  return  of  the  ague  fit.  On  looking  at  the  table  it  was  quite 
evident  that  the  giddiness  he  complained  of  on  the  21st  of  August  was 
the  precursor  of  the  fit  that  would  have  occurred  on  the  22nd,  had  not 
the  quina  been  used ;  and  again,  that  the  giddiness  which  recurred  on 
the  31st  of  August  was  the  first  shadow  of  the  fit  due  on  that  day,  and 
which,  no  doubt,  would  have  made  its  appearance  in  fuU  development 
on  the  3rd  of  September,  had  not  medicine  been  used.  A  knowledge 
of  this  law  will,  therefore,  prove  of  the  greatest  importance  in  enabling 
us  to  guard  against  the  return  of  the  disease ;  for,  for  several  weeks  after 
the  series  of  fits  has  ceased,  we  can  point  out  to  the  patient  on  what 
days  they  are  liable  to  reappear ;  and,  consequently,  he  can  upon  those 
days  more  effectually  guard  against  the  occasionally  exciting  causes  of 
the  disease,  such  as  cold,  fatigue,  &c.,  and  can  also  more  accurately 
prognosticate  his  distance  from  the  paroxysm  by  the  greater  or  lesser 
degree  of  health  which  he  feels  on  the  periodic  days.  As  long  as  they 
continue  as  free  as  the  intervening  days,  the  relapse  is  comparatively 
distant.  But,  to  return  to  our  history.  The  disease  appeared  now  much 
less  violent  than  before,  for  during  the  two  preceding  months  the  fits 
had  been  comparatively  slight  and  of  short  duration,  and  much  more 
under  the  control  of  medicine.  On  the  8th  of  September  he  went  to 
England.  By  way  of  precaution  I  ordered  him  to  continue  the  quina 
in  the  following  manner  :  He  was  to  take  five  grains  for  four  consecu- 
tive days,  and  then  to  omit  it  altogether  for  the  next  six  days,  at  the 
expiration  of  which  the  four-day  course  was  to  be  resumed.  Thus 
twenty  grains  were  given  every  ten  days.  This  plan  of  treatment  seemed 
to  be  attended  with  much  success.  For  more  than  two  months  he  had 
no  attack.  He  gained  flesh  and  improved  in  looks  and  spirits,  but,  just 
as  we  anticipated  the  realization  of  our  best  hopes,  the  disease  reappeared 
on  the  evening  of  October  the  15th,  so  that  from  the  date  of  the  last 
attack  on  the  10th  of  August,  sixty-four  days  had  elapsed  without  an 
attack,  and  by  reference  to  the  table  it  appears  that  the  15  th  of  Octo* 


376  CLINICAL   MEDICINE. 

ber  was  one  of  the  ague  days,  or  rather  of  the  periodic  days  :  so  that  the 
disease  suppressed  during  more  than  nine  weeks  had  yet,  for  the  whole 
of  that  time,  observed  its  latent  period  in  the  system,  and  reappeared 
with  wonderful  regularity  on  the  ague  day.  As  I  before  stated  he  had 
a  paroxysm  on  the  15  th  of  October  :  it  was  slight  and  occurred  in  the 
evening :  and  again  tolerably  severe  ones  occurred  on  the  18th  and  2]st 
of  October  at  early  periods  of  the  day  :  but  on  the  24th  the  fit  was 
postponed  to  seven  in  the  evening,  and  was  only  a  shadow.  Between 
the  16th  of  October  and  the  28th  he  took  fifty  grains  of  quina.  From 
the  benefit  derived  from  the  four-day  course  with  the  six-day  interval 
the  course  of  quina  was  again  commenced,  and  was  persevered  in  for 
nearly  five  months,  during  which  he  enjoyed  excellent  health  and  was 
free  from  every  symptom  of  disease,  having  taken  in  this  period  more 
than  200  grains.  However,  on  the  9th  of  March  his  old  enemy  once 
more  attacked  him.  The  fit  was  very  severe,  occupying  part  of  the  9th 
and  part  of  the  1 0th  of  March.  The  latter  was  the  day  on  which  it 
was  due  had  it  returned  according  to  the  usual  period.  This  can 
scarcely  be  considered  an  exception  to  the  usual  rule,  for  when  the  ague 
returns  after  a  long  interval  and  the  fit  is  severe,  occupying  the  latter 
haK  of  one  day  and  the  beginning  of  another,  we  have  already  seen  that 
the  sequel  alone  will  determine  from  which  of  the  days  we  are  to  date : 
allowing,  however,  this  to  be  an  exception  to  the  general  rule,  our 
period  becomes  once  more  dislocated,  and  we  set  out  anew  with  a  peri- 
odic time  dated  from  the  9th  of  March.  This  periodic  time  holds  true, 
indicating  after  an  absence  of  two  fits,  the  fit  of  the  18th  of  March,  and 
the  next  fit,  which  occurred  on  the  11th  of  April,  the  latter  interval 
consisting  of  twenty-three  days  between  the  two  fits.  There  was  a  fit 
on  the  14th  of  April,  another  on  the  17th,  and  another  on  the  20th; 
and  none  then  occurred  until  the  2nd  of  July.  According  to  the  new 
periodic  time  it  ought  to  have  occurred  on  the  1st  of  July.  In  this  free 
interval  of  seventy-two  days  the  periodic  time  failed  to  indicate  by  one 
day,  or  rather  by  haK  a  day,  the  reaccession  of  the  disease.  We  must 
therefore  again  take  a  fresh  day  of  departure,  from  the  2nd  of  July. 
Another  fit  occurred  on  the  5th  of  July.  No  fit  came  on  till  the  25th 
of  August,  that  is,  there  were  fifty  clear  days,  free  from  the  fit,  between 
these  two  paroxysms ;  and  the  latent  periodic  time  came  out  true.  No 
fit  occurred  until  the  2nd  of  November,  so  that  there  was  now  a  free 
interval  of  sixty-eight  days ;  and  the  latent  periodic  time  was  true  to  a 
day.  Taking  date  from  the  2nd  of  November,  we  have  next  an  interval 
of  forty-one  clear  days,  bringing  us  to  the  last  fit  on  the  14tli  of  Decem- 
ber, 1844,  which  coincides  with  the  periodic  time.  The  following  is  a' 
table  of  the  free  intervals  which  occurred  between  successive  series  of 


IlELAPSE-PERIODS    OF    AGUE. 


377 


fits,  showing  the  respective  duration  of  the  intervals  which  observed  the 
period,  and  those  wliich  did  not : — 


Table  A.  Free  Intervals  between  successive  Series  of  Pits. 


Interval. 

Periodic. 

Not  Periodic. 

Days  Free. 

Days  Free. 

1842 

1st 

17 

2n(l 

12 

3rd 

41 

4th 

44 

1843    < 

5th 
6th 

17 
14 

7th 

17 

8th 

14 

9th 

65 

10th 

136 

llth 

8 

12th 

23 

1844    - 

13th 

72 

14th 

50 

15th 

68 

16th 

41 

"! 

It  is  worth  remarking  that  aU  the  numbers  indicating  the  free  inter- 
vals, in  which  the  latent  period  was  observed,  consist  of  multiples  of 
three  plus  two — the  reason  is  obvious. 

By  this  it  appears  that,  in  thirteen  intervals,  the  latent  periodic  time 
was  preserved,  so  as  to  indicate  truly  the  day  on  which  the  disease  re- 
appeared ;  and  that,  in  the  remaining  three  the  indication  was  inaccurate 
by  a  half  a  day  or  more.  It  is  to  be  noted,  that  two  of  the  failures  oc- 
curred where  the  intervals  had  been  very  great.  We  may,  therefore, 
conclude  that  the  law  is  true  of  intervals  varying  from  ten  to  sixty  or 
seventy  days ;  in  much  longer  intervals  it  is  less  certain.  During  the 
year  1843,  twenty-seven  fits  occurred;  in  1844,  but  eleven,  most  of 
which  were  in  the  months  of  March  and  April,  and  some  of  the  latter 
were  among  the  most  violent  he  experienced.  The  disease,  therefore, 
did  not  wear  itself  out,  but  was  cured.  He  has  had  no  fit  during  the 
last  year,  and  has  remained  free  from  the  disease  since  the  14th  of 
December,  1844,  to  the  present  date. 

With  respect  to  the  manner  in  wliich  quina  was  used,  the  foUoAving 
observations  may  be  made.  At  first  I  gave  it  in  the  usual  manner, 
until  the  particular  series  of  fits  ceased ;  and  then  persisted  in  its  use 


378  CLINICAL   MEDICINE. 

for  ten  days  or  a  fortnight :  gradually  decreasing  the  quantity  taken. 
This  is  the  method  generally  recommended  by  authors,  and  it  is  founded 
on  the  notion,  that  it  is  necessary  where  the  medicine  is  given  in  large 
doses,  not  to  omit  its  use  abruptly,  lest  the  system  should  feel  the  loss 
of  this  powerful  tonic.  My  experience  in  this  and  other  cases,  leads 
me  to  doubt  the  accuracy  of  the  reasoning  upon  which  this  treatment 
is  founded,  and  I  am  convinced,  that  in  following  this  rule  we  defeat 
our  own  object,  by  accustoming  the  constitution  to  the  medicinal  effects 
of  the  quina  at  a  time  when  the  ague  fit  is  absent.  The  quina  is  the 
proper  antagonist  of  the  fit,  and  while  the  fits  require  this  medicine, 
it  is  borne  well  by  the  constitution.  On  the  contrary,  when  the  fits 
are  absent,  its  curative  effects  appear  to  be  diminished,  and  the  consti- 
tution becomes  so  accustomed  to  it,  that,  when  the  disease  again  re- 
quires it,  the  medicine  no  longer  exerts  its  anti-aguish  influence.  We 
have  an  analogous  example  in  the  case  of  mercury,  of  which  moderate 
quantities,  judiciously  exhibited,  are  sufficient  to  cure  the  venereal  dis- 
ease, provided  the  mercury  is  given  when  venereal  symptoms  are  pre- 
sent, and  only  in  the  quantity  necessary  to  control  these  symptoms.  If 
it  be  given  by  way  of  prevention,  when  these  symptoms  are  not  present, 
or  in  too  great  quantity  when  they  are,  the  system  in  either  case  be- 
comes saturated  with  the  mineral,  but  is  not  protected  from  the  further 
ravages  of  the  venereal  disease.  The  second  mode  of  treatment  which 
I  adopted  was  calculated  to  avoid  the  inconvenience  already  pointed 
out.  This  method  consisted  of  giving  the  quina  for  four  successive 
days,  and  intermitting  it  for  the  six  following  days,  thus  embracing  the 
interval  comprehended  in  three  fits.  By  these  means  it  was  hoped  to 
keep  the  system  sufficiently  under  the  curative  influence  of  quina  while 
we  avoided  rendering  the  constitution  too  familiar  with  the  medicine ; 
the  six-day  interval  preventing  it  from  becoming  saturated  by  the 
qurua.  This  method  of  treatment  seems  to  have  been  eminently  suc- 
cessful, and  under  its  influence  the  disease  abated  in  violence,  the  fre- 
quency of  the  attacks  decreased,  and  the  long  interval  of  136  days  was 
at  last  obtained.  Finding,  however,  that,  though  it  had  broken  the 
violence  of  the  disease  it  had  not  extinguished  it,  I  tried  another  on  the 
third  plan,  which  was  to  give  no  quina  until  a  well-marked  fit  or  shadow 
of  a  fit  occurred,  and  then  at  once  to  use  the  medicine  in  large  doses, 
so  as  to  stop  the  fits  as  soon  as  possible.  The  moment  this  object  was 
accomplished  the  medicine  was  omitted  and  was  not  again  given  until 
the  paroxysms  recurred,  when  they  were  similarly  treated.  This  on  the 
whole  appears  the  best  method,  as  it  stops  the  paroxysms  speedily,  and 
keeps  the  medicine  in  reserve  until  they  reappear.  The  following  table 
gives  a  general  view  of  the  quantity  of  quina  wliich  this  patient  took. 


RELAPSE-PERIODS    OP   AGUE.  379 

The  quina  was  prepared  by  Mr.  Donovan,  and  was  of  tlie  purest 
kind. 

On  the  whole,  I  conceive  the  readiest  method  of  giving  sulphate  of 
quina  to  be,  to  add  a  dose  of  the  powder  to  about  half  an  ounce  of  water 
at  the  time  it  is  to  be  taken ;  it  can  be  readily  mixed  by  stirring  with  a 
spoon;  and  by  this  means  it  may  be  swallowed  without  the  inconvenience 
which  attends  the  dose  when  acid  is  used  for  the  solution  of  the  quina, 
tlie  action  of  which  might  prove  injurious  to  the  teeth. 

During  the  summer  of  1843,  the  young  gentleman  whose  case  has 
been  related,  had  a  very  deHcate  and  unhealthy  appearance,  and  while 
he  was  under  the  kind  superintendence  of  Dr.  Stokes  at  Howth,  evident 
tumefaction  of  the  spleen  had  commenced.  He  is  now  robust  and  strong, 
and  has  regained  his  original  healthy  complexion. 


Table  (B.) 

Sulphate  of  Quina  taken  during  the  Years  1842,  1843, 
AND  1844. 


1842. 

Grain 

Dec. 

18,  Two  draughts. 

each  containing  gr.  v. 

=  x. 

}i 

20,  do. 

do. 

do. 

gr.  V. 

z:z  x. 

fi 

22,  do. 

do. 

do. 

gr.  viiss. 

=  XV. 

» 

23,  do. 

do. 

do. 

gr.  viiss. 

=  XV. 

Ji 

26,  do. 

do. 

do. 

gr.  viiss. 

=  XV. 

1843. 

Jan. 

1,  do. 

do. 

do. 

gr.  v. 

=  X. 

>i 

8,  do. 

do. 

do. 

gr.  viiss. 

=  XV. 

ji 

11,  do. 

do. 

do. 

gr.  viiss. 

=  XV. 

a 

21,  Pour 

do. 

do. 

gr.  viiss. 

=  XXX. 

a 

26,  Two 

do. 

do. 

gr.  viiss. 

=  XV. 

a 

29,  Pour 

do. 

do. 

gr.  V. 

=   XX. 

}> 

31,  Six 

do. 

do. 

gr.  V. 

=   XXX. 

Peb. 

5,  do. 

do. 

do. 

gr.  V. 

=   XXX. 

}y 

11,  do. 

do. 

do. 

gr.  iv. 

=  xxiv 

>) 

19,  do. 

do. 

do. 

gr.  iii. 

=  xviii 

380 


CLINICAL    MEDICINE. 


1843. , 

March  13,  Six  draughts, 
,,      16,  do.         do. 
„      18,  Tour 
„      22,  Six 
„       28,  do. 
April      3,  do. 
„         8,  do. 
„      15,  do. 
„      21,  do. 
May       4,  do. 
6,  do. 
June    15,  Mteen    do. 
July       2,  Two        do. 
3,  Ten 
„      23,  Six 
10,  Seven 
21,  Tour 
31,  Three 
5,  Pour 
8,  Eleven    do. 
5,  Pour  papers  of 

17,  do.         do. 

18,  Twelve    do. 
25,  Six  do. 

2,  do.  do. 

1,  Twelve    do. 

„      26,  do.  do. 

1844. 

Feb.       5,  do.  do. 

„      28,  do.  do. 

March  13,  do.  do. 

April      7,  do.  do. 

.,      15,  Six  do. 


Aug. 


Sept. 


Oct. 


Nov. 
Dec. 


do. 
do. 
do. 
do. 
do. 
do. 
do. 
do. 
do. 


do. 
do. 
do. 
do. 
do. 
do. 


Aug. 
Sept. 

Nov. 


25,  Twelve  do. 

18,  do.  do. 

4,  do.  do. 

7,  do.  do. 


each  containing 
•  do. 
do. 
do. 
do. 
do. 
do. 
do. 
do. 
do. 
do. 
do. 
do. 
do. 
do. 
do. 
do. 
do. 
do. 
do. 
quina,  in  each 
do. 
do. 
do. 
do. 
do. 
do. 

do. 
do. 
do. 
do. 
do. 
do. 
do. 
do. 
do. 


gr.  V. 
gr.  V. 
gr.  V. 
gr.  V. 
gr.  V. 
gr.  iv. 
gr.  iv. 
gr.  iii. 
gr.  iii. 
gr.  V. 
gr.  V. 
gr.  V. 
gr.  V. 
gr.  V. 
gr.  X. 
gr.  V. 
gr.  V. 
gr.  V. 
gr.  V. 
gr.  V. 
gr.  V. 
gr.  V. 
gr.v. 
gr.  vi. 
gr.v. 
gr.  V. 


gr.v. 
gr.  V. 
gr.  V. 
gr.  V. 
gr.  V. 
gr.  V. 
gr.  V. 
gr.  V. 
gr.  V. 


Grains. 

=  XXX. 

=  XXX. 

=  XX. 

=  XXX. 

=  XXX. 

=  xxiv. 
1=  xxiv. 
=  xviii. 
=  xviii. 

=  XXX. 
=   XXX. 

=  Ixxv. 

=   X. 

=  1. 

=  lx. 

=  XXXV. 
=  XX. 
=  XV. 
=   XX. 

=  lv. 

=  XX. 
=   XX. 

=  Ix. 
=z  xxxvi. 

=   XXX. 

=  Ix. 
=  Ix. 

=  Ix. 

=  lx. 

=  Ix. 

=  Ix. 

=  XXX. 

=  Ix. 
=  lx. 
=  lx. 
=  lx. 


Amounting  in  the  whole  to  grs.  1680, 
equivalent  to  three  troy  ounces  and  a  half,  of  which  he  took,  in  the  year 
1842,  grs.  65;  in  the  year  1843,  grs.  1105  ;  intheyear  1844,  grs.  510. 


RELAPSE-PERIODS    OF     AGUE. 


381 


The  two  Tables  marked  C  represent  the  fits  and  intervals  during  the 
years  1843  and  1844.  D.  F.  day  on  which  fit  occurred.  P.  T.  the 
periodic  time  carried  on  through  the  free  intervals.  W.  D.  marks 
where  the  latter  falls  on  the  wrong  day,  i.  e.  a  day  on  which  no  fit  oc- 
curred ;  a  new  series  here  commences  in  each  of  the  three  failures,  as  I 
before  explained. 


Table  (C).~1843. 


1 

1 

s 

1 

1 

1 

>> 

1 

June. 
July. 

1 

< 

i 

St: 

.S 
« 

ii 

1 

P.T. 

P.T. 

2 

P.T. 

P.T. 

D.F. 

D.F. 

RT. 

P.T. 

P.T. 
P.T. 

P.T. 
P.T. 

3 

P.T. 

D.F. 

1 

4 

P.T. 

■■ 

1 

P.T. 

3 

P.T. 

P.T. 

D.F. 

?.T. 

6 

P.T. 

D.F. 

P.T. 

P.T. 

7 

P.T. 

P.T. 

8 

D.F. 

P.T. 

j 

D.F. 

P.T. ; 

P.T.P.T. 

9 
10 

i  P.T. 

P.T. 

P.T. 

P.T. 

D.F. 

D.F. 

P.T. 

P.T. 

11 
12 

P.T. 

P.T. 

D.F. 

P.T. 

P.T. 

P.T. 

P.T. 

P.T. 

13 

D.F. 

P.T. 

'  14 

P.T. 

P.T. 

D.F. 

P.T. 

P.T. 

D.F. 

P.T. 

P.T. 

15 

P.T. 

P.T. 

16 

D.F. 

P.T. 

17 
18 

P.T. 

P.T. 

D.F. 

P.T. 

P.T. 

P.T. 

P.T. 

P.P. 

P.T. 

D.F. 

19 

P.T. 

1 

P.T. 

20 

W.D. 

P.T. 

P.T.  !  D.F. 

P.T. 

iIf! 

P.T. 

P.T. 

21 

D.F. 

P.T. 

P.T. 

22 

P.T. 

P.T. 

P.T. 

P.T. 

23 

P.T. 

P.T. 

D.F. 

24 

D.F. 

P.T. 

D.F. 

P.T. 
P.T. 

D.F 
P.T. 

25 
26 

P.T. 

P.T. 

P.T.jP.T. 

P.T. 

P.T. 

D.F. 

1  27 

D.F. 

P.T. 

D.F. 



28 

P.T. 

P.T. 

29 

P.T. 

P.T. 

P.T. 

P.T. 

P.T. 

P.T. 

30 

P.T. 

D.F. 

D.F. 

1 

31 

P.T. 

P.T. 

382 


CLINICAL    MEDICINE. 


Table  (C).— 1844. 


i 

c3 

1 

1 

1 

< 

1 

•-5 

s 

i 
ll 

1 

o 

"S 

o 

IJ 

li 

1 

P.T. 

P.T. 

P.T. 

W.D. 

P.T. 

1    1 

2 

P.T. 

P.T. 

D.F. 

D.F. 

P.T. 

3 

P.T. 

P.T. 

P.T. 

4 

P.T. 

P.T. 

P.T. 

P.T. 

5 

P.T. 

P.T. 

D.F. 

P.T. 

P.T. 

6 

P.T. 

P.T. 

P.T. 

7 

P.T. 

P.T. 

P.T. 

P.T. 

P.T. 

P,T. 

P.T. 

8 

P.T. 

P.T. 

9 

P.T. 

D.F. 

P.T. 

P.T. 

10 

P.T. 

W.D. 

P.T. 

P.T. 

P.T. 

P.T. 

11 

D.F. 

P.T. 

P.T. 

12 

P.T. 

P.T. 

P.T. 

P.T. 

13 

P.T. 

P.T. 

P.T. 

14 

D.F. 

P.T. 

P.T. 

P.T. 

D.F. 

15 

P.T. 

P.T. 

P.T. 

P.T. 

16 
17 

P.T. 

P.T. 

P.T. 

D.F. 

P.T. 

P.T. 

P.T. 

18 

P.T. 

D.F. 

P.T. 

P.T. 

19 

P.T. 

P.T. 

P.T. 

20 

D.F. 

P.T. 

P.T. 

P.T. 

21 

P.T. 

P.T. 

P.T. 

P.T. 

22 

P.T. 

P.T. 

P.T. 

23 

P.T. 

P.T. 

P.T. 

P.T. 

24 

P.T. 

P.T. 

P.T. 

P.T 

25 

P.T. 

P.T. 

D.F. 

26 

P.T. 

P.T. 

P.T. 

P.T. 

27 

P.T. 

P.T. 

P.T. 

P.T. 

28 

P.T. 

P.T. 

P.T. 

29 

P.T. 

P.T. 

P.T. 

P.T. 



30 

P.T. 

jP.T. 

P.T. 

3] 

P.T. 

P.T.I 

383 


LECTUEE  XXVII. 


CHOLEEA. ITS    ORIGIN    AND    PROGEESS. 

While  the  art  of  navigation  was  in  its  infancy,  and  communication  by 
land  between  distant  countries  unfrequent  and  insecure,  the  different 
races  and  families  of  mankind  who  dwell  far  asunder  on  the  earth's 
surface,  were  necessarily  unacquainted  with  the  appearance  of  new,  or 
the  existence  of  remarkable  diseases  amongst  each  other,  and,  conse- 
quently, that  department  of  medical  science  which  may  with  propriety 
be  termed,  the  Geography  of  Diseases,  remained  uncultivated.  Now, 
however,  we  approach  a  new  era,  when  the  means  of  intercourse  be- 
tween the  most  distant  nations  have  been  so  facilitated  by  the  aid  of  an 
improved  system  of  navigation,  a  commerce  almost  universal,  and  the 
daily  increasing  efficacy  of  steam  power,  that  we  many  indulge  in  the 
rational  hope  of  seeing  the  sciences  studied  after  a  new  method,  which 
will  embrace  within  the  range  of  observation,  not  merely  the  phenomena 
occurring  in  a  single  district  or  country,  but  those  which  take  place 
over  the  whole  surface  of  the  globe. 

Already  have  the  enlightened  efforts  of  our  own  University,  and  the 
genius  of  one  of  its  Professors,  prompted  the  rulers  of  many  king- 
doms to  join  in  an  alliance  destined  to  establish  magnetic  observatories 
in  distant  regions,  so  as  to  make  the  globe  of  the  earth  itself  a  subject 
of  extended  experiment ;  the  philosophers  of  the  new  world  have  com- 
bined with  those  of  the  old,  to  examine  simultaneously  meteorological 
phenomena,  and  already  have  the  records  preserved  by  observers  at  sea 
and  land,  revealed  the  hitherto  mysterious  course  of  storms,  and  enabled 
us  to  map  out  the  extent  and  direction  of  the  shocks  of  earthquakes. 
When  we  investigate  the  physical  changes  which  occur  in  our  planet, 
we  are  encouraged  to  repeat  and  multiply  observations,  in  the  hope  of 
discovering  general  laws,  whose  application  will  enable  us  to  explain 
the  past  and  predict  the  future.  But  the  surface  of  the  earth  abounds 
with  beings  in  whom  the  creative  powers  of  life  display  an  order  of 
phenomena  more  complicated  and  refined  than  anything  existing  in 


384  CLINICAL  m?:dicine. 

unorganized  matter.  But  for  this  very  reason,  and  on  account  of  this 
superiority  conferred  on  organized  matter  through  the  agency  of  vitality, 
each  being  thus  animated  is  governed  by  laws  which  seem  incapable  of 
extension  even  to  other  living  creatures  of  the  same  species ;  and  con- 
sequently we  are  led  to  expect  an  individuahty,  an  insulation,  among 
animals,  which  will  prevent  them  from  exhibiting  changes  occurring 
simultaneously  among  great  numbers,  and  capable  of  being  traced  to 
the  operation  of  general  laws. 

A  closer  examination,  however,  proves  that  animals  and  plants  are 
subject  to  the  operation  of  physical  agencies  which  act  upon  numbers 
of  individuals  at  the  same  time,  and  thus  give  rise  to  great  varieties  of 
diseases.  Such  diseases  should  be  made  a  special  object  of  study; 
many  of  them  are,  as  it  were,  fixed,  stationary,  and  confined  to  certain 
countries  and  districts.  Thus  the  goitre,  the  tumidum  sub  Alpibus 
guttuTy  has  from  the  earliest  times  been  endemic  in  the  valley  of  the 
Rhone,  and  other  parts  of  Switzerland;  modern  travellers  have  ob- 
served it  in  certain  parts  of  South  America,  and  in  Kemaon,  a  subalpiue 
department  of  Hindostan.  Agues,  typhus,  yeUow-fever,  elephantiasis, 
beri-beri,  Guinea-worm,  yaws,  Egyptian  ophthalmia,  are  chiefiy  con- 
fined to  the  inhabitants  of  certain  districts,  and  with  a  host  of  other 
complaints,  would  afi'ord  ample  materials  for  the  geography  of  fixed 
diseases. 

On  the  other  hand,  there  are  affections  of  men  and  animals  wliich 
travel  from  nation  to  nation,  and  tribe  to  tribe  ;  sometimes  these  mov- 
ing epidemics  progress  with  such  rapidity,  that  they  speedily  migrate 
over  the  whole  earth ;  at  other  times  they  creep  along  with  a  slow  and 
stealthy  step,  but  their  journey  is  continued  year  after  year,  until  they 
have  travelled  round  the  world.  The  Asiatic  cholera  affords  an  exam- 
ple of  the  latter  class,  having  been  twenty  years  in  compassing  the 
earth ;  while  influenza,  an  example  of  the  former,  often  traverses  the 
same  space  in  a  few  months.  Thus,  the  epidemic  influenza  of  1830-32, 
existed  in  Australia,  and  was  afterwards  noticed  in  the  northern  hemis- 
phere of  Moscow,  whence  in  eight  months  it  extended  to  St.  Peters^ 
burgh,  Warsaw,  Frankfort,  Paris,  London ;  three  months  subsequently, 
it  appeared  in  Italy,  and  shortly  afterwards  in  Gibraltar.  Now  it  is 
deserving  of  attention  that  this  influenza  travelled  from  Moscow  to 
London  in  eight  months,  and  to  the  United  States  of  America  in  seven 
months  more,  and  allowing  something  for  the  inaccuracy  of  dates,  these 
data  give  its  rate  across  the  Atlantic  only  a  Httle  speedier  than  across 
the  Continent. 

This  forms,  as  we  shall  hereafter  see,  a  striking  contrast  with  the  pro- 
gress of  cholera  from  Britain  to  Quebec,  as  compared  with  its  march 


CHOLERA.  385 

from  Moscow  to  London,  and  is  a  fact  of  considerable  weight  in  arguing 
whether  cholera,  like  influenza,  is  propagated  by  atmospheric  influences. 

The  influenza  of  1833,  travelled  much  more  rapidly  than  that  of 
1832,  for  originating  in  the  north-east,  there  was  but  a  few  days^ 
interval  between  its  appearance  in  Moscow,  Odessa,  Alexandria,  and 
Paris  ! 

The  influenza  of  1847,  however,  appears  to  have  travelled  with  still 
greater  rapidity ;  from  returns  received  at  the  office  of  the  Director- Ge- 
neral of  the  Navy,  Sir  Wilham  Burnett,  it  appears  to  have  prevailed  in 
January  and  February,  on  the  coast  of  Portugal  and  South  coast  of 
Spain ;  in  January,  Pebruary,  and  March,  in  Newfoundland  and  New 
Zealand  ;  in  February  and  March  at  Valparaiso ;  in  April,  on  the  coast 
of  Syria ;  July,  August  and  September,  west  coast  of  Africa  south  of 
the  equator,  and  in  August,  in  Hong  Kong  ! 

Influenzas  differ  from  each  other,  not  merely  as  to  their  rate  of  tra- 
velling, but  as  to  the  extent  of  the  earth^s  surface  which  they  affect. 
Some,  as  that  of  1782,  spread  from  China  all  over  the  inhabited  parts 
of  Asia,  Europe,  and  America ;  while  others,  as,  for  instance,  the  great 
influenza  of  1837,  did  not  reach  the  new  world  at  aU,  although  it 
passed  the  equinoctial  line,  and  was  severely  felt  at  the  Cape  of  Good 
Hope  and  Australia.  These  facts  are  alone  sufficient  to  stimulate  our 
curiosity,  and  ought  to  direct  the  attention  of  philosophers  as  well  as 
physicians,  to  to  the  study  of  endemic  and  epidemic  diseases ;  nor  will 
their  study  be  destitute  of  practical  benefit,  for  were  the  rulers  of  civi- 
lized nations  to  bring  into  active  operation  a  number  of  institutions, 
wliich,  discharging  the  functions  of  medical  observatories,  should  ob- 
serve and  record  the  appearance  and  symptoms  of  epidemics,  many 
curious  facts  relating  to  their  origin  and  progress  would  be  soon 
brouglit  to  light,  and  we  might  then  perhaps  be  enabled  to  arrive  at  a 
knowledge  of  some  general  laws  respecting  their  motions.  Thus,  we 
could  ascertain  whether,  as  has  been  asserted,  influenza  always  pro- 
gresses from  east  to  west,  never  from  west  to  east ;  whether  originating 
on  one  side  of  the  equator,  it  often  passes  to  the  other  ? 

As  the  means  of  communication  are  now-a-days  so  rapid,  it  is  quite 
possible  to  learn  the  character  and  the  best  mode  of  treating  an  epi- 
demic disease  long  before  its  arrival  amongst  ourselves ;  we  knew,  for 
instance,  the  symptoms  and  best  method  of  treating  the  influenza  of 
1837,  several  weeks  before  we  experienced  its  shock,  and  we  had  for 
many  years  been  familiar  with  the  symptoms  of  cholera  before  we  ac- 
tually witnessed  its  baneful  effects.  I  have  still  by  me  a  manuscript 
copy  of  a  lecture  I  gave  at  the  Meath  Hospital  in  1826  ;  in  that  lec- 
ture I  actually  described,  from  eastern  authors,  the  symptoms  of  spas- 
VOL.  I.  25 


386  CLINICAL    MEDICINE. 

modic  cholera,  and  prepared  the  class  for  its  future  arrival  in  Great 
Britain,  a  prediction  not  my  own,  but  derived  from  that  illustrious 
philosopher,  and  truly  excellent  man.  Dr.  Brinkley,  then  President  of 
the  Royal  Irish  Academy. 

The  origin  and  march  of  the  spasmodic  cholera  will  form  the  subject 
of  the  remarks  which  I  mean  to  lay  before  you  to-day.  In  India,  or 
more  properly  speaking,  in  Hindostan,  the  spasmodic  cholera  is  not  a 
new  disease;  partial  epidemics  of  it  have  occurred  at  different  times 
since  that  empire  has  been  familiarly  known  to  the  English.  These 
epidemics,  however,  being  almost  exclusively  confined  to  the  natives, 
comparatively  circumscribed  in  extent,  and  limited  in  duration,  did  not 
attract  much  attention  on  the  part  of  European  writers. 

^^  In  1762  it  prevailed  very  extensively  in  upper  Hindostan,  destroying, 
according  to  Le  Begue  de  Presle,  thirty  thousand  negroes,  and  eight 
hundred  Europeans.  Dr.  Paisley,  in  a  letter  from  Madras  in  1774, 
states  that  it  was  often  epidemic,  especially  among  the  blacks.  M.  Son- 
nerat,  in  the  account  of  his  travels  in  India,  between  the  years  1774 
and  1781,  mentions  that  cholera  prevailed  on  the  Coromandel  coast, 
and  at  one  period  more  particularly,  assumed  an  epidemic  and  malig- 
nant character.  Curtis,  in  his  work  on  the  Diseases  of  India,  and 
Girdleston,  in  his  essay  on  the  Spasmodic  Affections  of  that  country, 
speaks  of  an  unusual  prevalence  of  the  disease  during  1781  and  1782. 
It  prevailed  in  the  northern  Circars  in  the  early  part  of  1781,  and  in  the 
latter  end  of  March  it  affected  at  Gangam,  a  division  of  Bengal  troops, 
consisting  of  five  thousand  men,  who  were  proceeding  under  the  com- 
mand of  Colonel  Pears,  of  the  artillery,  to  join  Sir  Eyre  Coote's  army  on 
the  coast.  Men,  previously  in  perfect  health,  dropped  down  by  dozens, 
and  those  even  less  severely  affected,  were  generally  dead,  or  past  re- 
covery, within  less  than  an  hour.  Above  five  hundred  were  admitted 
into  the  hospital  in  one  day,  and  in  three  days,  more  than  half  the  army 
were  affected. 

"In  April,  1783,  it  broke  out  at  Hurdwar,  on  the  Ganges,  a  spot 
held  peculiarly  sacred  by  the  Hindoos,  among  a  crowd  of  between  one 
and  two  millions  of  persons,  assembled  for  the  purpose  of  ablution  in 
the  holy  stream.  It  is  the  custom  of  the  pilgrims  to  repair  to  the  bed 
of  the  river,  where  they  pass  the  night  with  little,  if  any  shelter.  Yery 
soon  after  the  commencement  of  the  ceremonies,  the  cholera  attacked 
the  pilgrims,  and  in  less  than  eight  days,  is  supposed  to  have  cut  off 
twenty  thousand  of  them.  The  disease  was,  however,  on  this  occasion 
so  confined  in  its  influence,  as  not  to  reach  the  village  of  Jawalpore, 
only  seven  miles  distant.''"^ 

*  American  Cholera  Gazette,  p.  3. 


CHOLERA.  387 

In  Europe  no  such  disease  as  spasmodic  cholera  had  been  known ; 
this  assertion,  though  opposed  to  some  authorities,  may  be  considered 
as  well  founded,  and  indeed  I  have  no  doubt  of  its  accuracy.  With 
us  spasmodic  cholera  is  an  imported  disease ;  in  Hindostan  a  resident 
epidemic.  What  causes  combined  to  convert  a  malady  habitually  con- 
fined to  the  Indian  peninsula,  into  a  disease  which  overshadowed  the 
earth,  sparing  no  nation  nor  language,  it  would  be  useless  to  inquire ; 
the  subject  is  buried  in  profound  obscurity  :  in  the  mean  time  let  us 
hope  that  it  will  not  prove  a  permanent  addition  to  the  nosology  of 
every  country,  and  that  it  will  soon  return  within  its  former  limits.  It 
was  in  the  spring  of  1817,  that  the  cholera  of  India  assumed  a  new 
and  more  powerful  character ;  it  was  then  it  became  endowed  with  pro- 
perties that  rendered  its  extension  steadily  progressive  over  the  earth, 
in  spite  of  all  the  obstacles  interposed  by  diversity  of  soil  or  climate. 
The  disease  first  assumed  the  migratory  and  epidemic  form  in  districts 
bordering  on  the  Ganges,  and  some  of  its  tributary  rivers,  at  a  distance 
varying  from  80  to  150  miles  from  Calcutta.  This  took  place  in  the 
spring  and  summer,  but  the  date  of  its  commencement  is  usually  re- 
ferred to  the  period  of  its  outbreak  at  Jessore,  on  the  19th  of  August, 
1817,  where  the  epidemic  was  first  immediately  observed  and  described 
by  Dr.  Tyler,  who  erroneously  attributed  it  to  the  use  of  bad  rice. 
Jessore  is  situated  in  the  Gangetic  Delta,  about  100  miles  north-east 
of  Calcutta.  The  cholera  was  now  observed  in  general  to  foUow  the 
course  of  the  rivers,  and  soon  arrived  at  Calcutta,  where  it  commenced 
its  ravages  in  September,  1817,  and  continued  to  rage  during  nearly 
the  whole  of  1818. 

^'  By  the  latter  end  of  September  the  disease  was  prevailing  through- 
out the  whole  province  of  Bengal,  from  the  most  easterly  limits  of 
Purnea,  Dinajepore  and  Silhet,  to  the  extreme  borders  of  Balasore  and 
Cuttack ;  and  from  the  mouth  of  the  Ganges  nearly  to  the  confluence 
of  that  river  with  the  Jumna,  a  space  of  upwards  of  four  hundred  miles, 
few  places  escaped  the  invasion,  and  the  cities  Dacca  and  Patna,  the 
towns  of  Balasore,  Burrissaul,  Rungpore,  and  Malda,  suiFered  severely. 
The  large  and  populous  city  of  Mooshedabad,  which,  from  extent  and 
local  position,  was  apparently  favourably  circumstanced  for  the  attacks 
of  the  epidemic,  it  is  remarkable,  escaped  with  comparatively  little  loss, 
while  all  around  was  severely  scourged. 

^^  During  the  autumn  of  1817,  the  disease  extended  itself  to  MuzufF- 
erpore  and  beyond  the  precincts  of  Bengal,  and  appeared  at  Chuprah, 
and  at  the  cantonment  of  Gazeepore ;  its  attacks  in  these  places  were, 
however,  confined  to  the  towns  themselves,  or  villages  in  their  imme- 
diate vicinity ;  the  principal  portion  of  the  adjoining  country,  at  this 


388  CLINICAL    MEDICINE. 

period,  entirely  escaping  the  disease.  Early  in  November  it  attacked 
the  grand  army,  then  stationed  at  Bundlecund,  a  portion  of  the  Allaha- 
bad province.  This  army  had  been  assembled  in  anticipation  of  a  war 
with  the  Pindarees,  and  the  centre  division,  consisting  of  ten  thousand 
fighting  men,  and  eighty  thousand  camp  followers,  was  encamped  on 
the  banks  of  the  Sinde,  under  the  immediate  command  of  the  Marquis 
of  Hastings.  Here  the  cholera  exercised  its  most  destructive  power. 
It  is  uncertain  whether  it  made  its  first  approaches  on  the  6  th,  7  th,  or 
8th  of  the  month.  After  creeping  about,  however,  in  its  wonted  insi- 
dious manner  for  several  days  among  the  camp  followers,  it  seemed  all 
at  once  to  have  gained  vigour,  and  burst  forth  with  irresistible  violence 
in  every  direction  extending  through  the  whole  camp  before  the  14th 
of  the  month.  Old  and  young,  European  and  native,  fighting  men  and 
camp  followers,  were  alike  subject  to  its  attacks,  and  all  equally  sunk 
in  a  few  hours  under  its  pestilential  influence.  It  was  a  common  occur- 
rence for  sentries  to  be  suddenly  seized  at  their  posts,  and  having  been 
carried  in,  to  have  two  or  three  successors  before  the  two  hours^  duty 
was  performed.  Many  of  the  sick  died  before  reaching  the  hospitals ; 
and  even  their  comrades,  whilst  bearing  them  from  out-posts  to  medical 
aid,  sunk  themselves  suddenly  seized  with  the  disorder.  The  mortality 
at  length  became  so  great  that  there  was  neither  time  nor  hands  to 
carry  off  the  bodies,  which  were  thrown  into  the  neighbouring  ravines, 
or  hastily  committed  to  the  earth  on  the  spots  where  they  expired,  and 
even  round  the  walls  of  the  officers^  tents.  In  the  five  days  included 
between  the  15th  and  20th  of  ISTovember,  the  number  of  deaths 
amounted  to  five  thousand.  The  natives,  thinking  their  only  safety  lay 
in  flight,  deserted  in  great  numbers ;  and  the  highways  and  fields  for 
many  miles  round  were  strewed  with  the  bodies  of  those  who  had  left 
the  camp  with  the  disease  upon  them,  and  speedily  sank  under  its  ex- 
hausting influence.  The  camp  being  now  cumbered  with  the  sick,  the 
Marquis  of  Hastings  determined  to  seek  a  purer  air  for  the  recovery  of 
his  sick.  Although  every  means  was  put  in  requisition  for  their  re- 
moval, a  part  was  necessarily  left  behind.  '  And  as  many  who  left  the 
carts,  pressed  by  the  sudden  calls  of  the  disease,  were  unable  to  rise 
again,  and  hundreds  dropped  down  during  every  subsequent  day's  ad- 
vance, and  covered  the  roads  with  dead  and  dying,  the  ground  of  en- 
campment, and  line  of  march,  presented  the  appearance  of  a  field  of 
battle,  and  of  the  track  of  an  army  retreating  under  every  circumstance 
of  discomfiture  and  distress.'^  The  exact  mortality  could  not  be  ascer- 
tained, but  it  appears  that  of  the  fighting  men  seven  hundred  and 

.  »  Bengal  Report,  pp.  12-15. 


CIIOLEllA.  389 

sixty-four  fell  victims ;  and  it  was  estimated  that  about  eight  thousand 
camp-followers,  or  one-tenth  of  the  whole,  were  cut  off.  On  arriving 
at  the  high  and  dry  banks  of  the  Betwah  at  Erich,  the  army  soon  got 
rid  of  the  pestilence,  and  met  with  returning  health. 

"  During  December  the  disease  appears  to  have  every  where  abated, 
and  in  January  of  1818,  to  have  become  nearly  extinct.  Towards  the 
latter  end  of  February  it  however  revived  with  great  force,  and  before 
the  close  of  the  year,  the  whole  peninsula  of  India,  from  Silhet  on  the 
east  to  Bombay  on  the  west,  and  from  Deyrah  on  the  north  to  Cape 
Comorin  on  the  south,  had  suffered  from  its  ravages.^^"^ 

The  ravages  of  the  disease  were  much  facilitated  and  increased  by 
the  superstition  of  the  people,  who,  in  obedience  to  the  Brahmins, 
collected  in  prodigious  multitudes  on  pilgrimages  to  certain  favourite 
sln-ines,  where  they  prayed  for  the  cessation  of  what  they  were  taught 
to  believe  the  cause  of  the  epidemic,  viz.,  a  violent  and  protracted 
battle  between  the  god  and  goddess  answerable  for  the  tranquillity  and 
happiness  of  that  part  of  the  world. 

During  the  year  1818  the  cholera  pursued  a  three-fold  route.  First, 
ascending  the  Ganges  and  the  Jumna,  it  reached  the  northern  pro- 
vinces of  Hindostan,  but  was  there  checked  in  its  progress  for  several 
years  by  the  Nepaulese  mountains,  and  finally  entirely  arrested  by  the 
Himalaya  range.  This  is  easily  accounted  for  by  the  thinness  of  the 
j)opulation  in  these  situations,  and  the  little  intercourse  wliich  takes 
place  between  the  mountainous  districts  and  lower  regions.  Cholera 
did  not  in  India  attain  to  an  elevation  beyond  six  thousand  feet  above 
the  level  of  the  sea ;  in  June,  1818,  it  had  reached  the  range  of  moun- 
tains between  Nepaul  and  Hindostan;  it  was  at  Schaurapoor,  many 
hundred  miles  to  the  north-west,  in  October ;  and  before  the  end  of 
the  year  had  ravaged  nearly  all  the  numerous  cities  and  villages  situated 
in  the  vast  tract  of  country  watered  by  the  Ganges,  the  Jumna,  and 
their  tributaries.  This  was  one  of  the  most  thickly  inhabited  parts  of 
India,  and  the  destruction  of  life  was  awful. 

The  second  route  was  southward  along  the  coast  from  one  sea-port  to 
another,  until  it  reached  Madras  on  the  20th  of  October,  1818.  Here, 
at  the  very  onset  of  the  disease,  twenty  medical  men  were  attacked,  of 
whom  thirteen  died, 

Sadras,  Pondicherry,  and  the  whole  Carnatic,  were  affected  during 
the  succeeding  year;  but  even  in  December,  1818,  it  had  reached 
Jaffnapatam,  the  most  northern  town  of  Ceylon,  having  passed  tliither 
after  travelling  along  the  whole  coast  of  Coromandel.     On  the  10th  of 

*  American  Cholera  Gazette,  p.  19. 


390  CLINICAL   MEDICINE. 

January,  1819,  it  broke  out  in  Colombo,  and  produced  dreadful  devas- 
tation on  the  western  coast  of  Ceylon ;  the  disease  became  exhausted 
there,  but  at  the  same  moment  burst  forth  with  renewed  vigour  in 
Candi,  the  capital,  2500  feet  above  the  level  of  the  sea.  The  cholera 
did  not  arrive  at  the  east  coast  of  Ceylon  until  1820,  when  it  appeared 
imported,  as  was  said,  into  Trincomalee  by  the  flag  ship  Leander.  The 
epidemic  was  brought  to  the  western  coast  of  the  Indian  peninsula, 
partly  by  sea  round  Cape  Comorin,  and  partly  by  the  great  over-land 
lines  of  communication  which  connect  the  Presidency  of  Bombay  with 
the  Presidencies  of  Madras  and  Bengal. 

It  first  showed  itself  at  Bombay  on  the  9th  of  August,  1820,  and  in 
that  Presidency  carried  of  150,000  persons. 

The  third  route  of  cholera  in  India  I  have  already  referred  to ;  it  was 
across  the  peninsula  from  the  east  coast  to  the  west.  It  came  by  Nag- 
poor,  EUishpoor,  Aurungabad,  Siroor,  and  Poonah,  to  the  Bombay 
coast,  and  was  introduced  either  by  troops  or  travellers. 

Prom  Ceylon  the  disease  went  to  the  Mauritius,  and  the  Isle  of 
Prance,  whither  it  was  said  to  have  been  imported  on  the  29th  of  Oc- 
tober, 1819.  The  distance  thus  traversed  at  one  spring  was  three  thou- 
sand miles.  Thence  it  soon  passed  to  the  Isle  of  Bourbon ;  and  in  the 
year  1820  to  the  east  coast  of  Africa  at  Zanguebar.  It  is  remarkable 
that  it  never  reached  the  Cape  of  Good  Hope,  where  the  strictest  qua- 
rantine was  observed. 

The  following  are  the  dates  of  its  arrival  in  the  subjoined  places : — 
Burmese  empire  generally;  Aracan.  Ava,  1819  ;  Malacca,  1818;  Su- 
matra, 1819;  Java,  Batavia,  (fearful,)  1821;  Madura;  Macassar; 
after  Batavia.  Amboina,  in  Moluccas,  1823.  Amboina  was  the  far- 
thest south-easterly  point  it  attained  to. 

The  disease  visited  Borneo  and  Celebes;  and  in  1820  broke  out  with 
extraordinary  violence  in  the  Philippine  Islands,  principally  at  Manilla, 
where  the  natives,  misled  by  the  idea  that  they  were  the  victims  of 
poison  administered  by  the  Europeans  and  Chinese,  rose  en  masse,  and 
were  not  put  down  until  15,000  lives  had  been  sacrificed  in  the  contest. 
Similar  manifestations  of  feeling  led  to  some  loss  of  life  even  in  Peters- 
burgh  and  Paris,  when  cholera  reached  these  cities.  The  same  sus- 
picions agitated  the  inhabitants  of  Europe  during  the  ravages  of  the 
black  death  in  the  fourteenth  century,  when  the  Jews  were  slain  in  great 
numbers  as  authors  of  the  plague.  In  Great  Britain  I  am  not  aware 
that  any  such  insane  popular  ideas  were  manifested  when  cholera  ap- 
peared. In  Ireland  nothing  of  the  sort  was  displayed ;  and  barbarous, 
cruel,  and  uneducated,  as  we  are  said  to  be,  the  visitation  was  in  no 
country  met  with  greater  intrepidity  and  resignation,  than  in  our  native 


CHOLERA.  391- 

land.  When  a  city  or  town  was  attacked  in  Ireland,  we  never  wit- 
nessed the  flight  of  the  better  classes ;  there  was  neither  migration  into 
the  country,  nor  desertion  of  their  poorer  fellow-citizens.  No ;  I  record 
the  fact  with  pride,  every  one  remained,  every  one  was  ready  to  do  his 
duty  and  abide  in  his  place  until  the  plague  was  stayed.  In  Dublin, 
and  generally  throughout  Ireland,  the  members  of  the  medical  Profes- 
sion, and  the  public  at  large,  believed  the  malady  to  be  contagious,  and 
yet  the  sick  were  never  abandoned  by  their  friends  in  private  houses, 
nor  in  the  least  neglected  in  the  hospitals. 

In  1819  the  cholera  appeared  in  Siam,  Bankok,  Tonkin,  Cochin- 
china,  and  caused  immense  loss  of  life  in  Cambodia.  In  1810  it  ar- 
rived at  Macao,  and  was  said  to  have  been  imported  by  some  ships  ; 
thence  it  travelled  to  Canton  in  China,  and  coming  to  Nanking  in 
1820,  penetrated  as  far  as  Peking  in  1821.  In  China  the  disease 
proved  particularly  fatal  on  account  of  the  denseness  of  the  population 
of  the  Celestial  Empire. 

So  far  we  have  followed  the  cholera  chiefly  southward  and  eastward 
in  the  first  instance,  but  afterwards  far  to  the  north ;  in  this  part  of  its 
course  it  passed  10°  to  the  south  of  the  line,  and  then  resuming  a 
northerly  direction,  went  on  to  Peking,  in  latitude  40°  north.  Even 
this  portion  of  its  progress  leads  forcibly  to  the  conclusion,  that  it  fol- 
lowed the  track  of  commerce,  whether  by  land  or  sea,  and  was  not 
dependent  for  propagation  on  mere  local  influences,  or  climate.  There 
is  a  popular  idea  current,  that  its  course  was  westward ;  such  was  the 
case  in  Europe,  hut  in  most  of  Asia  it  was  eastward. 

I  have  already  said  that  the  Himalaya  range  opposed  the  progress  of 
the  disease  northward  from  Hindostan,  and  that  the  highest  altitude  it 
attained  to  was  six  thousand  feet.  With  respect  to  this  latter  point,  I 
learned  from  my  friend  Captain  Meredith,  of  the  13th  Eegiment,  that 
it  broke  out  in  the  medical  depot  at  Landour  in  1838,  for  the  first 
time,  at  a  height  of  eight  thousand  feet  above  the  level  of  the  sea.  It 
is  worthy  of  remark,  that  cholera  did  not  come  to  New  Holland,  al- 
though it  was  in  several  islands,  as  Borneo,  and  Celebes,  to  the  north 
of  Australia ;  but  it  is  to  be  noted,  that  there  is  little  or  no  communi- 
cation between  them  and  the  settled  portions  of  New  HoUand. 

Let  us  now  trace  its  course  westward  from  Hindostan.  The  general 
belief  in  Persia  is,  that  the  disease  was  brought  in  ships  from  Bombay 
to  Mascate,  Bender-abassi  and  Bassorah,  in  which  places  it  appeared 
nearly  at  the  same  period,  in  spring,  1821. 

Erom  Bassorah  and  Bender-abassi,  the  epidemic  spread  in  a  well- 
defined  and  marked  manner,  along  the  rivers  and  routes  most  fre- 
quented by  commercial  travellers. 


392  CLINICAL   MEDICINE. 

Thus  from  Bassorali  it  crept  up  the  Euphrates  and  Tigris ;  and  iii 
August^  1821.  was  at  Bagdad^  where  it  carried  off  great  numbers  of 
the  Persian  army  then  besieging  that  city.  Along  the  Euphrates  it 
proceeded  to  the  ruins  of  Babylon,  and  by  the  great  route  of  the  cara- 
vans across  the  Desert,  it  arrived  at  Aleppo.  Here  it  did  not  commit 
great  ravages,  and  ceased  in  the  following  December ;  but  afterwards 
extended  to  different  towns  in  Asia  Minor,  as  Mosul,  Merdin,  Darbeker. 
At  Alexandretta,  situated  on  the  Gulf  of  Scanderoon,  it  did  not  arrive 
until  1823.  It  is  strange  that  cholera  did  not  continue  very  long  in 
Asia  Minor  or  Syria,  and  did  not  at  that  period  penetrate  into  Egypt. 

Erom  Bender-abassi  in  Persia,  cholera  travelled  along  the  great  mer- 
cantile road  to  Shiraz  in  August,  1821 ;  and  thence  to  Yezd,  where  it 
appeared  towards  the  end  of  September,  but  on  the  approach  of  winter 
lay  dormant  until  spring,  1822,  when  it  again  showed  itself,  and  spread 
north-westward,  committing  the  greatest  ravages  in  every  town  and 
village  situated  on  the  great  caravan  road.  Tauris,  Korbia,  Ardabil, 
and  the  provinces  of  Kalkhai,  Masinderan,  and  Gilan,  (on  the  Caspian,) 
were  soon  infected.  In  most  of  these  places  it  seemed  to  cease  for  a 
time,  but  reappeared  in  the  middle  of  1823;  and  travelling  along  the 
Persian  seaports  of  the  Caspian,  it  reached  the  province  of  Shirwan, 
then  lately  ceded  to  Eussia.  Here  it  ascended  the  river  Cur,  and  pro- 
gressed along  the  high  roads  to  the  fortress  Buku;  and  on  the  21st 
September,  1823,  Astrachan  was  attacked.  In  June,  1823,  cholera 
showed  itself  in  the  neighbourhood  of  Laodicea  and  Antioch,  (modern 
names,)  and  then  spread  in  two  directions  along  the  coast  of  the  Medi- 
terranean, but  disappeared  again  both  there  and  on  the  coast  of  the  Cas- 
pian Sea. 

On  the  whole  then,  the  epidemic,  from  its  commencement  in  1817, 
till  the  end  of  1823,  had  travelled  over  ninety  degrees  of  longitude,  and 
sixty-six  degrees  of  latitude,  viz.  from  the  Phihppine  Islands  to  the 
coast  of  Asia  Minor,  and  from  the  island  of  Bourbon,  to  Astrachan,  and 
to  the  Caspian  Sea. 

It  is  very  remarkable  that  cholera  did  not  come  to  Europe  by  way  of 
Asia  Minor ;  this  circumstance  may  perhaps  be  explained  by  the  accident 
of  its  not  having  infected  Smyrna,  the  chief  seaport  of  communication 
between  Asia  Minor  and  Europe.  Had  Egypt  likewise  been  then  attacked 
by  cholera,  it  is  doubtful  whether  Europe  would  have  been  so  long  spared. 
Be  this  as  it  may,  from  the  end  of  1823,  until  its  outbreak  at  Orenbourgh 
in  1829,  cholera  seemed  to  halt  on  the  very  confines  of  Europe,  so  that 
we  may  consider  the  years  from  1817  to  1823,  as  constituting  the  first  ^ 
period  in  the  progress  of  this  epidemic.  ^ 

But  although  the  cholera  ceased  to  attract  much  attention  in  Europe 


i 


CHOLERA.  393 

during  the  interval  which  elapsed  between  1823  and  1829,  yet  we  are 
not  on  that  account  to  conclude  that  it  lay  entirely  dormant,  for  we  find 
it  continued  its  ravages  in  its  original  seat,  India,  and  extended  itself 
from  Asia  Minor,  Persia,  and  China,  through  the  vast  regions  of  Tartary 
and  Chinese  Tartary. 

The  thinness  of  the  population  in  these  half  desert  regions,  may  be 
the  reason  why  the  progress  of  the  disease  through  them  was  at  once  so 
uncertain  and  so  slow ;  the  want  of  frequent  communication  between 
even  neighbouring  districts,  may  have  baffled  for  a  time  the  march  of  the 
pestilence,  and  may  have  occasioned  its  remarkably  slow  progress  towards 
the  Russian  frontier.  Certain  it  is  that  this  march  in  Persia,  Tartary, 
Mongolia,  and  Thibet,  countries  absolutely  destitute  of  regular  roads, 
formed  a  striking  contrast  with  its  rapid  transmission  through  more 
populous  and  highly  cultivated  countries,  or  its  still  quicker  passage 
from  one  maritime  nation  to  another,  when  connected  by  a  constant 
trade  as  from  Germany  to  England,  from  England  to  Canada,  and  from 
the  East  Indies  to  the  Isle  of  Prance.  In  the  latter  cases  the  epidemic 
sprung  from  one  country  to  another ;  hut  it  is  remarhable  that  it  never 
traversed  the  ocean  at  a  rate  exceeding  that  of  ships. 

We  next  come  to  the  second  period  of  the  history  of  cholera,  when 
it  broke  out  at  Orenbourgh,  in  August,  1829,  where  it  raged  with  great 
violence,  spreading  throughout  the  whole  of  that  Russian  province ;  while 
the  disease,  after  long  lingering  in  the  north  of  Persia  assumed,  in 
]  829,  an  increased  energy  in  that  kingdom,  from  whose  northern  por- 
tions it  spread  along  the  western  coast  of  the  Caspian,  arriving  at  Sahan, 
and  the  province  Shirwan  in  June,  1830 ;  and  thus  spreading  to  Baku, 
Kuba,  and  Sheki,  in  Chomath  Talisch,  and  in  the  district  Elizabethpol. 
Prom  this  the  epidemic  pursued  a  two-fold  route ;  the  one  following 
the  Kura,  upwards,  led  to  Tifiis,  where  the  mortality  reached  five 
thousand  :  and  thence  to  the  Black  Sea  and  the  Caspian,  until  it  a  se- 
cond time  reached  Astrachan,  and  proved  much  more  fatal  in  that  city 
than  in  1823,  now  counting  more  than  eight  thousand  victims. 

Prom  Astrachan  the  progress  of  the  cholera  up  the  Wolga  or  Yolga, 
was  very  remarkable,  as  it  spread  from  town  to  town  on  that  river,  in 
the  direct  route  of  intercourse  and  traffic.  I  may  here  remark,  that 
whenever  cholera  travels  up  the  highest  mountain  passes,  as  in  India, 
or  traverses  the  ocean,  as  to  the  Isle  of  Bourbon,  or  accompanies  the 
caravan  across  the  desert,  as  when  it  arrived  at  Mecca  and  Medina,  or 
when  it  ascends  rivers,  making  the  towns  on  its  banks  the  successive 
stages  of  journey  :  in  all  such  cases,  cholera,  I  say,  seems  regulated  by 
no  common  physical  circumstance,  except  human  traffic  and  human  in- 
tercourse ;  for  in  other  things  these  lines  or  routes,  differ  remarkably 


394  CLINICAL   MEDICINE. 

from  each  other.  But  to  follow  its  ascent  of  the  Yolga  :  in  1830,  in 
August,  it  came  to  Saratow,  and  shortly  after  to  Kasan,  Nijni-Nov- 
gorod,  Kostroma,  Jarislaw,  and  so  on  to  the  circle  Tischwin,  in  the 
government  Novgorod,  where  it  was  only  250  versts  distant  from 
Petersburgh,  and  where  it  attained  for  that  year  to  its  highest  northern 
limit. 

Erom  the  country  between  the  Caspian  and  Black  Sea,  it  spread 
through  the  Caucasus  to  the  Don,  which  it  ascended,  while  it  coasted 
the  Black  Sea  to  Cherson  and  Odessa,  in  September  and  October, 
1830. 

The  stream  of  cholera  which  entered  Eussia  from  the  northern  pro- 
vinces of  Persia,  as  it  may  be  seen  from  the  foregoing  account,  soon 
formed  a  junction  with  that  which  flowed  from  Tartary  through  Oren- 
bourgh. 

In  the  middle  of  September,  1830,  the  disease  appeared  in  the  go- 
v»nment  of  Moscow ;  and  on  the  20th  of  September  in  the  capital 
itself,  and  did  not  cease  until  the  following  March.  In  Moscow  a 
severe  frost  and  snow  set  in  towards  the  end  of  November,  without  in 
the  least  diminishing  the  diffusion  or  the  intensity  of  cholera.  Its  un- 
abated continuance  throughout  the  whole  of  a  Moscow  winter,  is  a  fact 
worthy  of  attention ;  in  Moscow,  according  to  Jahnichen,  there  sick- 
ened between  thirty  and  forty  per  cent,  of  the  persons  who  had  hospital 
duty  to  perform,  including  physicians,  nurses,  &c.,  wliile  of  the  whole 
population  not  more  than  three  per  cent,  took  the  disease.  In  Dubhn 
likewise  great  numbers  of  the  hospital  attendants  were  affected,  and 
many  died ;  still  more  were  saved  by  the  timely  exhibition  of  remedies. 
It  is  not  quite  correct  to  affirm  that  cholera  ceased  in  Moscow  in  March, 
for  in  the  autumn  of  1831  more  than  one  thousand  cases  occurred. 

During  the  winter  and  spring,'  1830-31,  cholera  spread  far  to  the 
west  and  south,  viz.  to  Kaluza,  Tula,  Pultawa,  Kiew,  Podolia,  Bessa- 
rabia, Bulgaria,  and  Silistria,  and  through  the  river-provinces  of  the 
Dnieper,  the  Bug,  and  the  Dniester. 

In  the  more  northerly  and  eastern  governments,  the  disease  had 
ceased,  while  it  continued,  though  in  a  milder  form,  in  the  provinces 
Nicolajaw,  Crakow,  Tauris,  and  among  the  Cossacks  of  the  Black  Sea. 
Petersburgh  a  second  time  remained  untouched,  although  the  disease 
had  arrived  at  Tishwin,  within  one  hundred  miles  of  it,  an  immunity  to 
be  attributed  to  the  strict  precautionary  measures  adopted,  and  the 
cordon  sanitaire  drawn  around  the  capital  for  the  protection  of  its  inha- 
bitants, but  not  of  its  emperor,  Nicholas,  who,  it  is  but  just  to  add,  had 
gone  to  Moscow  the  moment  he  had  ascertained  the  existence  of  cho- 
lera in  that  city,  in  order  to  exert  himself  in  alleviating  the  sufferings 


CHOLERA.  395 

of  his  subjects.  The  fear  of  infection  proved  no  obstacle  to  the  Czar_, 
who  zealously  performed  his  duty  on  that  trying  occasion. 

The  war  in  Poland  accelerated  the  invasion  of  cholera  into  that  un- 
happy country,  into  which  the  Russian  army  commenced  its  march  on 
the  5th  of  Pebruary,  1 831,  in  tliree  columns,  of  which  many  battalions 
came  from  infected  provinces.  Thus  the  governments  of  Yolhynia, 
Grodno,  and  Wilna,  were  extensively  under  the  influence  of  disease  in 
the  spring  of  1831.  During  this  campaign  the  Eussian  army  lost  great 
numbers  by  cholera,  and  Marshal  Diebitch  himself  died  at  Pultusk,  on 
the  10th  of  June,  1831,  of  a  few  hours^  illness — a  circumstance  which 
gave  rise  to  the  unfounded  rumour  that  he  was  poisoned ;  the  details 
of  his  illness  have  been  pubHshed  by  an  eye-witness.  Dr.  Koch,  of 
the  Prussian  service.  In  Warsaw  the  disease  appeared  on  the  14th  of 
April,  after  the  battle  of  Iganie,  where  the  Poles  took  many  prisoners, 
who  were  brought  to  Warsaw.  In  Poland  the  disease  advanced  and 
retreated  with  the  infected  armies  in  a  striking  and  remarkable  manner. 
Westwards  and  southwards  from  Warsaw,  it  spread  rather  slowly  to- 
wards the  Prussian  confines,  arriving  on  the  23rd  July  at  Kozieglow, 
a  little  town  nine  miles  south  of  Czenstochowa,  and  but  two  German 
miles  from  the  frontier  of  Silesia. 

Northwards  the  disease  had  spread  in  March  and  April,  through 
Lithuania,  to  the  sea-ports  of  the  Baltic,  particularly  Riga.  Prom 
Riga  the  cholera  advanced  through  Gourland  and  Liefland  (Livonia.) 

Petersburgh  was  now  threatened  on  every  side,  for  the  disease  broke 
out  with  renewed  violence  in  the  European  provinces  formerly  affected, 
while  most  of  those  which  had  hitherto  escaped  suffered  in  their  turn. 
Under  these  circumstances  the  metropolis,  considering  the  great  quan- 
tity of  goods  and  passengers  who  arrive  by  water-carriage  from  the  in- 
terior of  the  country,  could  not  be  expected  to  remain  long  exempted, 
although  all  possible  precautions,  short  of  entirely  preventing  com- 
munication with  the  country,  were  adopted;  accordingly  cholera  ap- 
peared in  Petersburgh  in  July,  1831.  Yery  serious  disturbances  arose 
in  the  Russian  metropolis  among  the  lower  orders,  who  considered  the 
pestilence  as  artificially  produced  for  their  destruction  by  secret  friends 
of  struggling  Poland.  These  troubles  were  only  appeased  by  the  pre- 
sence of  the  emperor,  but  not  before  the  mob  had  destroyed  the  cholera 
hospital,  and  murdered  one  of  the  physicians.  During  this  epidemic 
seventeen  medical  men  died  in  Petersburgh,  and  a  great  many  others 
were  attacked,  some  slightly,  some  severely.  The  hospital  nurses,  por- 
ters, and  attendants,  suffered  in  a  very  large  proportion,  as  did  a  great 
number  of  the  mob  engaged  in  sacking  the  cholera  hospital.  Cholera 
had  already  invaded  several  of  the  most  northern  provinces  of  Russia, 


396  CLINICAL  MEDICINE. 

and  had  arrived  at  Archangel  in  May,  1831.  Archangel  is  the  most 
northern  emporium  of  commerce  in  the  world,  and  is  the  highest  lati- 
tude attained  to  by  cholera,  which  in  a  population  of  19,000  destroyed 
more  than  ]200.  In  the  beginning  of  August  cholera  arrived  at  Hel- 
singfor ;  and  of  September,  at  Abo  in  Finland.  After  this  Aland  and 
the  neighbouring  islands  were  affected,  and  so  it  passed  into  Sweden. 
Dantzic,  30th  May,  1831;  Elbing,  11th  July;  consequently  eleven 
weeks  after  its  appearance  in  Dantzic  :  but  there  was  an  interruption, 
or  rather  a  great  diminution  of  the  intercourse  between  these  towns. 
From  Dantzic  the  disease  radiated  in  every  direction  throughout  the 
neighbouring  province.  Thorn,  21st  July,  1831 ;  Konitz,  22d  August, 
Memel,  27th  July;  Konigsburgh,  22nd  July.  Here  a  formidable  cho- 
lera insurrection  took  place.  Stettin,  25th  August,  1831 ;  Berlin,  30tli 
August;  Frankfort  on  Oder,  end  of  September;  Magdeburgh,  3rd 
October. 

From  Magdeburgh  the  disease  spread  extensively  upwards,  along  the 
course  of  the  Elbe.  Halle,  20th  December,  1 831 ;  Merseburgh,  1st 
January,  1832;  Breslau,  23rd  September,  1831.  In  the  first  months 
of  1832,  cholera  had  nearly  disappeared  from  the  German  provinces  of 
Prussia.  Deaths  31,000.  Aamburg,  7th  October,  1831.  Mecklen- 
burg, 7th  October,  1831.  Mecklenburg-Schwerin  took  most  extraor- 
dinary precautions,  and  escaped. 

Saxony,  though  Prussia  and  Austria  on  either  side  of  it  were  severely 
visited,  adopted  strict  measures  of  precaution,  and  escaped ;  the  cho- 
lera was  neither  at  Leipzic  or  Dresden  !  Hanover  also  escaped,  with 
the  exception  of  Liineburg,  22nd  October,  1831.  Sachsen- Weimar, 
Gotha,  Anhalt,  Hessia,  Brunswick,  and  some  other  small  principalities, 
all  escaped,  and  apparently  by  the  same  means,  viz.,  non-intercourse 
with  infected  places. 

In  some  Saxon  villages,  as  Cosing  and  Edderitz,  the  disease  broke 
out  but  did  not  spread,  apparently  in  consequence  of  the  measures  of 
precaution  instantly  put  in  force  by  the  authorities. 

Austria  suffered  most  severely;  Brody,  (Gallicia,)  5th  May,  1831; 
Limberg,  22nd  May ;  all  over  Gallicia  in  1831.     Died  97,770. 

Cracow  seems  to  have  been  infected,  not  from  Poland,  but  from 
Gallicia. 

Beginning  of  July,  1831,  cholera  began  in  Hungary.  In  beginning 
of  June,  1831,  much  popular  violence.  Spread  very  rapidly.  Pesth, 
middle  of  July;  Presburgh,  9th  September,  1831. 

In  Hungary  cholera  had  ceased  as  an  epidemic  by  the  beginning  of 
April,  1832,  having  proved  fatal  to  at  least  240,000  persons  !  Vienna, 
15th  August,  1831 ;  Prague,  28th  November,  1831. 


CHOLEIU.  397 

Bohemia  was  widely  affected ;  but  the  disease  did  not  spread  from 
Vienna  far  either  to  the  south  or  west,  and  accordingly  Carinthia, 
Stiermark,  and  the  Tyrol  escaped,  all  being  protected  by  the  strictest 
precautionary  measures. 

It  is  worthy  of  being  noted,  that  cholera  remained,  as  it  were,  sta- 
tionary and  in  a  suppressed  form  during  the  winter  of  1831  and  32, 
in  Hungary,  Bohemia,  and  Germany.  It  did  not  spread  into  Saxony, 
Mecklenburg,  Bavaria,  and  scarcely  into  Hanover,  although  these  bor- 
dered on  infected  states,  an  immunity  not  to  be  accounted  for  by  the 
existence  of  any  natural  boundaries,  as  mountains  or  rivers,  for  the 
limits  are  mostly  conventional  between  the  infected  principalities  and 
those  which  escaped ;  many  have,  therefore  attributed  their  escape  to 
the  precautionary  measures  taken.  It  is  strange  that  Leipsic  was 
spared,  whille  Halle  suffered  so  long  and  so  severely ;  the  situation  of 
the  former  city  appearing  to  be  much  more  favourable  to  the  develop- 
ment of  miasma  than  that  of  the  latter. 

Moldavia,  in  spring  of  1831.  In  Jassy  the  deaths  exceeded  6000,  out 
of  a  population  of  27,000.  The  disease  began  in  June;  and  no  doubt 
its  diffusion  was  favoured  by  the  unhealthy  position  of  the  town,  and 
the  condensation  of  a  wretched  population,  chiefly  Jews  and  Gipsies, 
in  its  filthy  narrow  streets.  AU  the  medical  men,  except  three,  perished 
with  most  of  their  families.  Bucharest,  July,  1831 ;  Bulgaria,  July, 
1831 ;  Constantinople,  July,  1831;  Adrianople,  GaUipoli,  Philippopili, 
September,  1831. 

It  is  to  be  noted,  that  plague  broke  out  in  Constantinople  at  the 
same  time  with  cholera ;  but  while  the  latter  epidemic  ceased  towards 
the  end  of  September,  the  former  continued  for  several  months  longer. 
Cholera  now  a  second  time  invaded  Asia  Minor,  and  simultaneously 
with  plague  caused  great  devastations.  Corfu,  October,  1831 ;  Mo- 
nastori,  in  Greece,  November,  1831. 

The  destruction  of  religious  pilgrims  at  Mecca  was  appalling.  The 
place  resembled  a  field  of  battle,  so  great  were  the  numbers  of  the  un- 
buried  dead ;  and  at  last  even  the  fanaticism  of  Mussulmans  was  forced 
to  yield,  and  the  survivors  sought  safety  in  a  hasty  and  tumultuous 
flight.  Three-fourths  of  the  pilgrims  are  calculated  to  have  perished 
during  the  three  days  they  were  densely  crowded  together  at  Mecca ; 
and  of  the  fugitives  10,000  fell  victims  on  their  journey.  The  Pasha 
of  Egypt  now  repeated  the  precautions  so  successful  in  1823,  but  this 
time  they  were  taken  in  vain,  because,  as  is  supposed  by  many,  they 
were  not  resorted  to  sufiiciently  soon ;  be  this  as  it  may,  cholera  broke 
out  first  at  the  two  quarantine  stations,  where  the  pilgrims  from  Arabia 
were  detained ;  and  in  the  middle  of  August,  1831,  it  appeared  in  Cairo 


398  CLINICAL   MEDICINE. 

and  Damietta.,  and  towards  tlie  end  of  the  month  in  Alexandria.  Egypt 
lost  on  the  whole  150,000.  The  cholera  ascended  the  Nile,  and  was 
at  Luxor,  the  site  of  ancient  Thebes,  by  the  end  of  September. 

We  next  find  the  cholera  visiting  England,  it  arrived  about  the  4th 
of  November  at  Sunderland,  a  seaport  directly  opposite  to,  and  com- 
mercially connected  with  Hamburgh.  The  cholera  spread  through 
many  towns  in  the  north  of  England,  but  did  not  any  where  rage  with 
very  destructive  violence,  a  circumstance  attributable  perhaps  to  the 
more  complete  separation  of  families  in  Great  Britain,  as  compared  with 
our  continental  neighbours.  The  existence  of  the  disease  was  announced 
on  the  27th  of  January,  1832,  in  Edinburgh,  and  on  the  10th  of  Ee- 
bruary  in  London.  The  ravages  of  the  cholera  in  the  metropolis  were 
comparatively  insignificant,  its  victims  during  the  whole  epidemic  not 
exceeding  1500. 

It  is  exceedingly  remarkable,  how  many  of  the  great  towns  of  Eng- 
land either  escaped  infection  altogether,  or  were  visited  by  only  a  trifling 
outbreak  of  the  disease.^  Up  to  the  24th  of  June,  1832,  (that  is 
during  a  period  of  about  eight  months  since  its  first  appearance  in  Sun- 
derland), the  total  number  of  cases  throughout  Great  Britain,  inclusive 
of  London,  amounted  to  only  14,796,  and  the  deaths  to  5,432.t  The 
disease,  it  is  true,  continued  in  many  places  to  linger  long  after  the 
above  date,  and  reappeared  as  an  epidemic  in  some  places  in  1833  and 
1834 ;  but  still  we  are  quite  warranted  in  concluding,  that  on  the  whole 
in  Great  Britain  and  Ireland,  the  cholera  did  not  count  30,000  victims. 
In  Ireland,  particularly  in  Dublin  and  Sligo,  the  mortality  was  much 
greater  than  in  England — an  occurrence  which  may,  perhaps,  be  ac- 
counted for  by  the  bad  diet  of  the  Irish  lower  classes,  and  the  crowded 
state  of  their  dwellings,  it  being  well  known  that  in  the  worst  quarters 
of  the  city,  many  famiUes  reside  on  the  same  floor,  and  frequently  more 
than  one  in  the  same  room.  "In  London,^^  says  Dr.  Eniotson,J  "the 
greater  part  of  the  people  are  well  fed,  better  fed  than  in  any  other 
part  of  the  world ;  they  eat  more  meat,  and  the  flesh  is  of  such  quality 
as  scarcely  to  be  found  in  any  other  country.  Besides  which,  they  are 
better  clothed  and  more  comfortable ;  and  instead  of  trashy  wines  they 
have  good  sound  ale  and  porter,  and  malt  liquor  of  all  kinds.  But  in 
Paris  the  water  the  inhabitants  drink  is  very  bad;  the  people  are 
crowded  together,  I  know  not  how  many  families  in  a  house,  with  little 
ventilation.     The  streets  are  narrow,  the  houses  dirty ;  and  the  popu- 

*  Cholera  commenced  in  Liverpool  on  the  12th  of  May,  and  in  the  meantime  had 
visited  Hull,  York,  Leeds,  Manchester,  and  Warrington, 
f  JMedical  Gazette,  vol.  x.  p.  400. 
+  Medical  Gazette,  vol.  xii.  p.  628, 


CHOLERA.  399 

lation  live  upon  what  Englislimen  consider  trash,  not  roast-beef  and 
mutton,  but  all  sorts  of  dishes  made  up  of  bread  and  vegetables,  with 
a  little  meat  boiled  in  water  to  colour  it  or  give  it  a  flavour ;  and  drink 
not  good  beer,  but  thin  wine/^ 

Certain  it  is,  no  matter  how  we  may  attempt  to  account  for  it,  that 
cholera  was  much  more  destructive  in  Paris  than  in  London,  385  deaths 
having  occurred  in  one  day,  8th  April  1832,  in  the  former  city.  No- 
thing has  puzzled  or  perplexed  the  continental  physicians  more  than  the 
comparative  immunity  from  cholera  enjoyed  by  England,  notwithstand- 
ing their  predictions,  that  there  its  ravages  would  attain  to  a  maximum^ 
for  they  contended,  that  in  the  English  towns  many  circumstances  would 
contribute  to  render  the  disease  more  liable  to  spread,  as  for  example, 
their  very  dense  population,  the  extreme  poverty  and  bad  diet  of  the 
lower  orders,  and  the  damp,  foggy  nature  of  the  climate.  Now,  I  be- 
lieve, that  the  reproaches  made  by  foreigners  respecting  the  extreme 
penury  of  the  lowers  orders  in  England  are  not  well  founded,  at  least 
comparatively  speaking,  and  with  reference  to  the  same  class  of  persons 
in  the  continental  cities ;  and  I  am  persuaded  that  in  English  cities  the 
diet  of  the  poor  is  superior  to  that  of  the  continental  poor.  Indeed 
foreign  physicians  have  tried  their  ingenuity  to  account  for  the  slight- 
ness  of  the  ravages  of  cholera  in  Great  Britain,  some  attributing  the 
immunity  to  tea,  some  to  the  quantity  of  meat  we  consume,  and  some 
to  the  vapours  arising  from  our  numerous  coal  fires ;  and  each  of  these 
hypotheses  have  been  met  by  objections,  for  the  Chinese,  the  most  na- 
tional tea  drinkers  in  the  world,  were  wofuUy  scourged  by  cholera; 
and  the  city  of  Halle,  in  Germany,  the  most  devastated  town  of  that 
kingdom,  uses  nothing  but  coal  for  firing.  It  is  to  the  more  substan- 
tial nature  of  English  fare,  to  the  superior  cleanliness  of  that  nation, 
and  to  their  living  in  families  separated  from  each  other,  that  we  must 
attribute  their  comparative  exemption  from  cholera,  an  exemption  the 
more  remarkable,  when  we  consider  that  in  England,  commercial  and 
private  travelling  between  town  and  town  is  more  rapid,  and  ten  times 
more  frequent  than  on  the  continent. 

Cholera  first  appeared  in  Paris  on  the  24th  of  March,  1832,  and  it 
has  been  argued  by  those  who  deny  the  contagious  nature  of  cholera, 
and  its  importation  from  abroad,  that  in  Prance  it  broke  out  suddenly, 
not  on  the  confines,  but  in  the  heart  of  the  kingdom,  and  consequently 
that  it  must  have  arisen  spontaneously  in  the  metropohs.  Before  we 
attach  much  weight  to  this  argument,  we  must  have  very  strong  proofs 
that  the  facts  are  as  above  stated.  Now,  it  is  very  remarkable  that 
cholera  was  officially  announced  to  exist  at  Calais  only  eight  days  after 
it  appeared  at  Paris  :  and  when  we  recollect  how  unwilhng  the  autho- 


400  CLINICAL   MEDICINE. 

rities  in  all  sea-ports  of  liitherto  unaffected  nations,  have  invariably 
been  to  acknowledge  tlie  existence  of  cholera,  it  is  not  by  any  means 
improbable  that  cholera  may  have  existed  in  Calais  before  it  broke  out 
in  Paris — a  supposition  confirmed  by  the  report  of  Arnaud,  Moribaud, 
and  Gendrin,  who  witnessed  in  Calais,  towards  the  end  of  1831,  many 
very  violent  cases  of  cholera  resembling  the  Asiatic ;  nay,  even  after 
the  cholera  had  manifestly  appeared  in  Calais,  many  persisted  in  de- 
claring that  its  victims  died  of  common  enteritis. 

We  see  cholera  introduced  probably  from  England  to  Calais,  and 
immediately  after  to  Paris,  from  which  it  radiated  in  all  directions  by 
slow  and  varying  stages,  all  over  the  kingdom.  The  position  of  Paris, 
and  its  daily  communication  with  England,  rendered  it  almost  the  first 
prey  of  the  disease  in  Prance.  Once  there,  the  cholera  moved  along 
the  different  lines  of  communication  in  every  direction,  its  route  not 
governed  by  any  of  the  laws  observed  by  epidemics  depending  on  atmos- 
pheric changes;  and  its  gradual  progress  from  Paris,  as  a  centre, 
towards  aU  parts  of  the  circumference  of  Prance,  presenting  a  course 
obviously  opposed  to  that  of  such  epidemics. 

Prom  England  cholera  soon  spread  to  Ireland ;  the  following  dates 
of  its  arrival  were  communicated  by  Dr.  Barker,  whose  official  situation 
in  the  Board  of  Health,  gave  him  the  best  opportunity  of  ascertaining 
the  progress  of  the  disease. 


Places. 

Dates  of  outbreak  of 
Cholera. 

Dublin 
Arklow 
Banbridge 

Cork               

Ramelton,  County  Donegal 

Naas 

Belfast 

Warren-point 

Stranorlar,  County  Donegal 

Tralee             

Galway 

Limerick 

Waterford       ... 

Wexford         

22nd  March,  1832. 

8th  April, 

9th  April,         ,, 
12th  April, 
12th  April, 
13th  April, 
14th  April, 
17th  April,         ,, 
22nd  April, 
28th  April, 
12th  May, 
14th  May, 
1st  July,             „ 
21st  August,      ,, 

It  is  worthy  of  remark  that  Dublin,  Cork,  and  Belfast  were  affected 
about  four  months  before  Waterford  and  Wexford.  Now  a  steamer 
plies  twice  a  week  between  Dublin  and  Cork,  and  Dublin  and  Belfast, 
wTiile  there  is  no  direct  communication  hy  steam  between  Dubhn  and 
Waterford,  or  Dublin  and  Wexford ;  and  consequently  it  appears  pro- 
bable, from  the  dates,  that  Cork  and  Belfast  were  infected  from  Dublin, 


CHOLERA.  401 

while  Waterford  and  Wexford  escaped  for  many  monthsj  not  being  ex- 
posed to  infection  from  this  source.  At  all  events,  the  fact  that  Water- 
ford  and  Wexford  should  have  remained  so  long  without  the  disease  is 
very  remarkable,  and  if  not  sufficiently  accounted  for  by  their  more 
indirect  and  less  frequent  intercourse  with  Dublin,  it  may  perhaps  be 
explained  by  their  trade  with  England  consisting  chiefly  of  the  export 
of  agricultural  produce,  rather  than  the  interchange  of  passengers. 


VOL.  I.  26 


402 


LECTURE  XXVIII. 

CONTAGIOUS  CHARACTER  OF  CHOLERA TREATMENT. 

We  have  liitherto  followed  the  route  of  cholera  in  the  old  world^  wg  have 
now  to  trace  it  in  the  new. 

"The  disease  commenced  about  the  8th  of  June,  1832,  in  Quebec, 
in  boarding-houses  and  taverns  in  the  Cut  de  Sac,  a  low,  uncleanly,  and 
ill  ventilated  part  of  the  city,  crowded  with  emigrants  of  the  lowest  des- 
cription, with  sailors,  and  other  persons  of  irregular  habits.''"^ 

Thus  we  find  that  cholera  appeared  in  America  first  at  Quebec,  just  at 
the  season  when  the  spring  stream  of  emigration  from  England  reaches 
that  city.  The  following  account  proves  that  cholera  might  be  thus 
transmitted : — 

"  The  following  letter  from  the  surgeon  of  the  British  barque  Brutus, 
to  the  president  of  the  Board  of  Health  of  Liverpool,t  conveys  the 
melancholy  intelligence  of  the  cholera  having  broke  out  among  the  pas- 
sengers eight  days  after  leaving  the  river  Mersey,  and  which  induced 
the  captain  to  put  back.  It  appears  from  a  statement  subjoined  to  the 
letter,  that  between  the  27th  of  May,  the  period  when  the  first  person 
was  attacked,  and  the  13th  of  June,  the  day  on  which  the  vessel  arrived 
at  Liverpool,  117  cases  had  occurred,  81  died,  and  20  had  recovered. 

" '  With  the  deepest  feelings  of  regret,  I  have  the  painful  duty  to 
perform  of  transmitting  to  you  one  of  the  most  melancholy  and  dis- 
tressing accounts  of  cholera,  which  occurred  on  board  the  British  barque 
Brutus,  bound  for  Quebec,  from  Liverpool,  with  three  hundred  and 
thirty  passengers.  The  first  case  presented  itself  on  the  25th  of  May, 
(being  the  eighth  day  after  we  left  the  river,)  in  a  strong,  healthy  man, 
thirty-five  years  of  age ;  the  symptoms  were  all  well  marked,  the  spasms 
particularly  severe;  under  the  usual  means  of  treatment  he  recovered. 

*  See  the  official  Report  of  the  Board  of  Health,  Quebec  Cholera  Gazette,  p.  72. 
•\  Cholera  Gazette. 


CHOLEllA.  403 

Tlie  next  case  was  an  old  woman  of  sixty,  who  died  in  ten  hours  after 
the  commencement  of  the  attack.  The  disease  continued  gradually  to 
increase,  (notwithstanding  every  means  having  been  employed  to  arrest 
its  progress,)  until  the  night  of  Saturday,  the  2nd  of  June,  when  we 
were  a  good  deal  tossed  about  by  a  heavy  sea,  and  dark  hazy  weather ; 
it  spread  to  such  an  alarming  extent,  that  on  Sunday,  most  of  the  ship's 
crew  being  attacked,  and  having  lost  some  of  them  the  week  before,  we 
were  obliged  to  bear  up  again  for  Liverpool.  It  is  impossible  to  describe 
the  scene  of  misery  on  the  third,  fourth,  and  fifth,  people  dying  in  every 
direction — the  greater  number  of  them  destitute  of  the  common  articles 
of  bed  covering.  On  the  sixth,  the  weather  became  more  favourable, 
the  disease  less  severe,  and  the  number  of  new  cases  diminished,  which 
has  since  been  on  the  decline.  W.  W.  Thompson."  " 

On  the  10th  of  June,  1832,  it  appeared  at  Montreal,  and  here,  as  at 
Quebec,  it  immediately  assumed  the  character  of  a  most  destructive 
pestilence. 

The  following  interesting  account"^  of  the  route  of  cholera  during  the 
first  stages  of  its  progress  in  North  America,  is  from  the  pen  of  S.  Jackson, 
M.D.,  Secretary  to  the  consulting  Medical  Board  of  Pliiladelphia.  Dr. 
Jackson  is  a  non-contagionist,  as  will  abundantly  appear  from  his  narra- 
tive, upon  some  of  the  leading  facts  of  which  I  may  hereafter  take  occasion 
to  make  a  few  observations.  It  is  worthy  of  remark  that  the  medical 
men  of  America  have  far  outstripped  their  European  colleagues  in  me- 
dical statistics.  The  weekly,  monthly,  and  annual  accounts  of  diseases, 
deaths,  &c.,  in  each  of  their  great  cities  have  been  long  published  sys- 
tematically and  regularly,  and  that  with  a  degree  of  accuracy  to  which 
we  are  strangers.  Some  of  the  results  of  this  praiseworthy  habit  appear 
in  Dr.  Jackson's  account. 

'^  Trom  the  numbers  of  emigrants  who,  about  this  period,  had  landed 
at  Quebec,  and  arrived  at  Montreal  from  England  and  Ireland,  a  first 
impression  was  created,  that  they  had  been  the  means  of  transmitting  the 
epidemic  across  the  Atlantic.  A  more  close  investigation  into  the  facts 
connected  with  the  commencement  of  the  disease  in  these  cities,  served 
to  destroy  this  supposition.  It  could  not  be  traced  to  importation.  The 
emigrants  and  lower  classes  of  the  Canadians  were  attacked  simultaneously 
in  both  cities.  Numbers  of  the  emigrants  were  in  circumstances  emi- 
nently predisposing  them  to  suffer  attacks  of  the  disease,  and  they  and 
the  lower  Canadians  were  precisely  the  description  of  persons  most 
obnoxious  to  the  ravages  of  epidemic  cholera,  and  such  as  have  been 
universally  observed  to  be  its  first  victims. 

*  Cholera  Gazette. 


404  CLINICAL    MEDICINE. 

"The  lines  of  communication  between  the  cities  of  Quebec  and 
Montreal,  and  the  cities  of  the  United  States,  are  by  the  Richelieu 
River,  Lake  Champlain,  and  the  northern  canal  leading  to  Troy  and 
Albany ;  or  by  the  St.  Lawrence  to  Lake  Ontario,  to  Buffalo,  and  by 
the  Erie  Canal  leading  to  Rochester  and  Albany.  It  was  confidently 
expected  that  the  disease  would  penetrate  into  the  United  States  from 
Canada  by  these  routes.  Along  the  first,  many  cases  of  the  disease  did 
certainly  occur  in  the  persons  of  emigrants,  but  they  terminated  with- 
out its  communication  to  others.  On  the  contrary,  the  epidemic  mani- 
fested a  decided  predilection  for  the  shores  of  the  St.  Lawrence,  suc- 
cessively attacking  the  towns  and  villages  along  its  banks,  then  follow- 
ing the  borders  of  Lake  Ontario,  until  it  entered  Lake  Erie. 

"  While  attention  was  directed  to  the  northern  and  western  boundary, 
supposed  to  be  tlireatened  by  the  invasion  of  the  disease,  it  suddenly 
and  most  unexpectedly  appeared  in  the  city  of  New  York. 

'^The  first  case  occurred,  it  is  said,  on  the  24th  of  June,  when  a 
man,  a  native  citizen,  residing  at  the  corner  of  Gold  and  Erankfort 
streets,  was  attacked  by  the  disease.  Eour  cases  soon  succeeded,  the 
location  of  which  was  in  Cherry-street.  The  subjects  were  Irish  emi- 
grants, who  had  arrived  in  Quebec  in  the  autumn  of  1831,  and  had 
resided  in  Albany  until  the  month  of  May,  when  they  removed  to  New 
York. 

"On  the  27th  of  June,  the  disease  manifested  itself  in  Belvue  Alms- 
house, distant  about  three  miles  from  the  city.  The  patient  was  an 
aged  woman  who  had  not  left  the  house  for  three  years,  who  had  held 
no  communication  with  the  city,  and  no  admission  into  the  ward  she 
occupied  had  taken  place  for  a  month.  Several  cases  immediately  en- 
sued in  this  and  the  other  wards  of  the  house.  The  epidemic  reached 
its  maximum  in  this  establishment  on  the  1 1th  July,  and  terminated  on 
the  4th  August. 

"  In  the  city  of  New  York,  the  climax  of  the  epidemic  arrived  on 
11th  of  July,  from  which  period  it  continued  very  steadily  to   decline. 

"  The  time  that  elapsed  from  the  outbreaking  of  the  epidemic  at 
Quebec,  and  its  appearance  at  New  York,  is  a  period  of  sixteen  days, 
or  nineteen  at  Belvue  Almshouse.  The  distance  between  the  two  cities 
in  a  direct  line,  is  four  hundred  and  fifty  miles. 

"  It  is  to  be  remarked  that  all  the  intermediate  cities  on  the  sea- 
board of  the  province  of  New  Brunswick  and  Nova  Scotia,  of  the 
states  of  Maine,  Massachussetts,  and  Rhode  Island,  remained  entirely 
exempt  from  the  epidemic ;  and  even  to  the  present  period,  except  in 
Providence,  Newport,  and  Boston,  no  cases  have  as  yet  appeared. 

"  In  this  city,  the  epidemic  was  much  more  tardy  in  its  progress  than 


CHOLERA.  405 

it  had  been  in  the  Canadas,  or  in  New  York.  The  first  decided  case  of 
cholera  occurred  on  Thursday,  July  5th.  A  man  of  the  name  of  Mus- 
grove,  residing  in  the  cellar  of  a  house  in  Pilbert-streetj  near  Schuylkill 
Fifth-street,  was  attacked  with  symptoms  of  malignant  cholera  on  that 
day.  This  man  had  but  lately  been  discharged  from  the  New  Jersey 
prison ;  he  had  been  affected  with  diarrhcea  for  two  or  three  weeks  pre- 
vious to  the  cholera  symptoms.  The  disease  proved  fatal  on  Sunday 
the  8th.  The  next  case  was  a  black  man  residing  in  St.  John-street, 
Northern  Liberties,  above  Callow-hill.  He  had  been  employed  work- 
ing on  board  a  ship  from  England,  lying  at  Pratt'tj-wharf.  He  was 
seized  with  symptoms  of  mahgnant  cholera  the  night  of  Tuesday,  July 
9th,  and  died  on  Friday.  This  man  was  perfectly  sober  in  habits ;  no 
premonitory  symptoms  existed. 

*^^No  other  cases  presented  themselves  until  Sunday,  July  14th, 
when  two  females  occupying  a  room  in  a  dwelling  in  Coate's-street, 
were  the  victims  of  the  pestilence  in  its  most  aggravated  shape. 
Both  these  females  were  exemplary  in  their  habits  of  life,  but  ap- 
peared to  be  infirm  in  health.  The  husband  of  one  of  these  un- 
fortunates had  arrived  on  Saturday,  July  7th  from  New  York,  exceed- 
ingly alarmed  respecting  the  cholera.  He  was  taken  sick  the  next  day, 
and  died  on  the  succeeding  Friday.  On  Saturday  the  widow  felt  un- 
well, and  without  advice  took  sixteen  grains  of  calomel  in  the  evening. 
She  was  soon  afterwards  seized  with  vomiting  and  purging,  and  in  the 
course  of  the  night  she  sunk  into  collapse.  She  died  Sunday  night. 
The  mother  of  the  deceased  husband  on  Sunday  morning  complained 
of  feeling  unwell,  but  without  definite  symptoms.  Having  been  up 
with  her  daughter-in-law  during  the  night,  her  uncomfortable  feeling 
was  attributed  to  fatigue.  She  was  then  going  about  the  house,  and 
had  been  out  on  an  errand.  She  was  requested  to  lie  down,  as  a  mat- 
ter of  precaution,  and  a  small  dose  of  opium  administered  to  her.  This 
was  at  eight  o^ clock  in  the  morning.  Dr.  Schott,  who  was  in  attendance 
an  hour  afterwards,  went  up  to  her  chamber  to  inquire  into  her  state. 
He  found  her  lying  on  the  floor ;  copious  dejections  of  rice-water  look- 
ing fluid  had  occurred,  and  she  was  in  complete  collapse :  death  ensued 
in  the  evening.  These  were  the  only  cases  to  which  the  slightest  sus- 
picion of  communication  by  contagion  could  attach ;  but  on  the  same 
day,  a  Frenchwoman,  temperate  in  habits,  about  fifty  years  of  age, 
living  in  Kensington,  beyond  the  close  built  part  of  the  town,  at 
the  head  of  West-street,  was  also  a  victim  of  the  disease.  This 
woman  had  not  been  from  her  dwelhng  for  three  weeks ;  her  house 
is  isolated,  being  surrounded  by  kitchen-gardens,  for  the  supply  of 
the  market.     She   had  been  affected  with  diarrhoea  since  Friday,  for 


106 


CLINICAL   MEDICINE. 


which  she  had  dieted ;  but  had  taken  no  medicine.  The  case  proved 
fatal  next  day. 

"  From  this  time  not  more  than  three  or  four  cases  occurred,  all 
scattered  in  different  quarters,  particularly  Kensington,  Northern  Li- 
berties, and  Southwark,  until  the  27  th  and  28th  July,  when  the  epidemic 
fairly  set  in,  and  cases  continued  daily  to  be  developed.  The  disease  at- 
tained its  height  in  this  city  on  the  5th,  6th,  and  7th  of  August,  since 
which  time  it  has  gradually  declined,  and  appears  now  to  be  extinct. 

"Taking  the  27th  or  28th  of  July  as  the  proper  commencement  of 
the  epidemic  in  Philadelphia,  there  will  be  a  period  of  twenty-four  or 
twenty-five  days  intervening  between  its  first  appearance  in  New  York 
and  this  city.     The  distance  in  a  direct  line  is  about  ninety  miles. 

"  A  comparative  view  of  the  population,  number  of  cases  and  deaths 
in  the  cities,  which  have  been  brought  under  observation,  presents  the 
epidemic  in  an  interesting  point,  and  exhibits  in  a  clear  manner  the 
character  it  assumed  in  this  city. 


Date  of  Report  and 
Place. 


Popula- 
tion. 


Ratio  of 
Cases  to 
Popula- 
tion. 


Ratio  of 

Deaths 

to  Cases. 


Ratio  of  Deaths 
to  Population. 


Sept.  30,  Quebec      - 

,,       1,  Montreal  - 

Aug.  22,  N.  York    - 

Sept.  13.  Philadelphia 


32,000*  5783 

28, 000 1  4385 

140,000§|5547 

160,0001[i2314 


3292t 
1853 

27821 
935 


in  5  l-7th 
in  61 
in25i 
in  70 


1  inli 
lin2i 
1  in  2 
lin2i 


1  in  10| 

1  in  15  l-9th 

1  in  15i 

I  in  173.29-183 


"  The  results  of  this  table  show  conclusively,  that  the  causes  productive 
of  cholera  were  less  numerous  in  the  city  of  Philadelphia  than  in  Quebec, 
Montreal,  or  New  York,  or  were  so  modified  as  to  possess  a  much  less 
degree  of  activity.  The  causes  of  this  result,  so  favourable  to  Philadel- 
phia, important  in  the  hygienic  history  of  cholera,  and  consoling  to  hu- 
manity, as  placing  this  formidable  affection  to  so  great  an  extent  under 
control,  it  is  interesting  to  investigate. 

"  The  following  are  the  circumstances  which,  existing  more  particularly 
in  Philadelphia,  may  be  regarded  as  influential  in  ameliorating  the  vio- 
lence of  the  epidemic  cause,  circumscribing  its  activity,  and  diminishing 
its  fatality. 

"  1.  The  plan  on  which  the  city  is  built,  arranged  in  hollow  squares, 

*  "  Permanent  population,  27,000  ;  transient  population,  5000.— Total,  32,000. 
+  "  Protestant  grounds,  1244  ;  Catholic  cathedral,  and  cholera  grounds,  to  25th  Sep- 
tember, 1574  ;  at  St.  Roch,  470 Total,  3292. 

+  "  Permanent  population,  25,000  ;  transient  population,  3000 Total,  28,000. 

^^  •'  Estimated  as  remaining  by  Mr.  D.  Leslie.  — Journal  of  Commerce,  Aug.  8th. 

II  "  Report  of  the  Inspector. 

^!  "  Population  within  the  bill  of  mortality." 


CHOLERA.  407 

separated  by  wide  and  paved  streets,  prevents  excessive  crowding  of  the 
inhabitants,  procures  free  ventilation,  and  gives  facility  to  the  means  of 
cleanliness.  It  is  to  be  regretted  that  any  deviation  has  been  permitted 
in  the  original  design  of  Penn,  whose  sagacity  and  foresight  has  been  so 
amply  demonstrated  in  the  circumstances  of  the  late  epidemic. 

"  2.  The  abundant  supply  of  wholesome  water  placed  at  the  command 
of  the  whole  community,  affords  a  healthful  beverage,  and  gives  the 
means  of  the  most  complete  cleanliness,  by  washing  the  dirty  gutters  of 
the  streets,  close  alleys,  and  lanes. 

"  3.  The  well  arranged  measures  of  sanitary  police,  devised  and 
actually  carried  into  effect  by  the  councils  of  the  city,  and  the  boards  of 
commissioners  of  the  district,  and  the  sanitary  committees  appointed  by 
them,  and  by  the  Board  of  Health.  The  measures  consisted  in  a  thorough 
investigation  into  all  existing  nuisances,  and  in  their  immediate  abate- 
ment ;  iu  a  complete  system  of  cleanliness  of  the  city  steadily  pursued ; 
in  the  early  establishment  of  numerous  local  hospitals,  provided  with 
ample  medical  attendance,  nurses,  and  every  means  applicable  to  the 
treatment  of  the  disease ;  and  in  spreading  before  the  public  early  infor- 
mation, derived  from  the  consulting  medical  committees,  of  the  methods, 
hygienic,  dietetic,  and  medicinal,  best  adapted  for  guarding  against  the 
attack  of  the  disease,  or  to  arrest  the  symptoms  at  its  onset. 

"4.  A  very  considerable  influence  may  be  attributed  to  the  annun- 
ciation made  by  the  mission  sent  to  Canada,  immediately  on  its  return, 
and  before  the  epidemic  had  commenced  its  career  in  this  city,  of  the 
different  periods  of  the  disease,  and  especially  of  the  existence,  in 
almost  every  instance,  of  premonitory  signs,  and  a  preliminary  stage, 
with  a  description  of  the  symptoms  indicating  its  existence.  This  in- 
formation was  communicated  to  the  public  by  the  sanitary  committee 
through  the  daily  journals  of  the  city,  by  handbills  liberally  distributed, 
and  by  placards  on  the  corners  of  the  streets.  The  Board  of  Health 
adopted  the  same  measures,  and  pursued  the  same  course.  In  this 
manner  the  whole  community,  before  the  beginning  of  the  epidemic, 
was  instructed  in  the  most  important  points  in  the  general  knowledge 
and  management  of  this  affection — ^its  commencing  period,  the  pre- 
monitory symptoms,  its  general  curability  in  that  state,  the  necessity 
of  immediate  attention  and  medical  advice,  and  the  methods  of  relief. 
These  facts  had  been  overlooked,  and  this  attention  to  the  instruction 
of  the  public  was  entirely  neglected  in  Quebec  and  Montreal,  and  in 
New  York.  From  being  taken  unprepared  by  the  epidemic,  earlier 
than  was  anticipated,  they  were  not  communicated  to  the  public  until 
the  measure  had  been  adopted  in  this  city,  and  when  the  epidemic  there 
had  already  attained  its  maximum  of  intensity. 


408  CLINICAL  MEDICINE. 

'^5.  The  moral  resolution,  calmness,  and  a  perfect  freedom  from 
alarm  and  panic,  generally  manifested  by  our  citizens,  and  inspired  by 
a  thorough  confidence  in  the  efficacy  of  the  preventive  means  enforced, 
in  the  advantages  for  salubrity  of  the  city,  and  in  its  medical  resources, 
contributed  in  no  small  degree  to  diminish  the  number  of  cases,  and  the 
intensity  of  the  attacks.  No  stores  were  closed  on  account  of  the  epi- 
demic, and  not  more  citizens  left  the  city  than  usually  abandon  it  every 
summer.  A  stranger  entering  our  streets,  from  the  busy  throng  and 
cheerful  aspect  of  all  he  met,  would  never  have  suspected  the  existence 
of  an  unusual  and  a  desolating  scourge. 

"  6.  The  treatment  of  the  disease  generally  pursued  in  the  city,  in 
the  preliminary  stage,  had  most  probably  no  small  share  in  preventing 
the  development  of  the  disease  in  innumerable  instances.  In  the 
lighter  forms,  it  was  limited  chiefly  to  diet,  rest,  tranquillizing  doses  of 
anodynes,  or  mild  diffusibles,  with  occasionally  the  mildest  laxatives  or 
gentle  cathartics,  conjoined  with  sinapisms  or  other  rubefacients.  The 
drastic  and  perturbating  cathartics  were  seldom  if  at  all  prescribed,  and 
the  stimulant  practice  but  rarely  resorted  to. 

"  The  foregoing  circumstances  appear  to  us  as  those  principally  in- 
strumental in  producing  the  favourable  results  attending  the  epidemic 
in  this  city.  As  such  they  acquire  a  high  degree  of  interest,  and  afford 
most  instructive  lessons  as  regards  the  measures  of  municipal  and  civil 
regulation  connected  with  sanitary  police. 

"  In  its  general  features  and  character,  the  disease  differed  in  no  re- 
spect from  the  many  descriptions  that  have  been  made  since  it  first 
attracted  attention  in  Asia,  and  subsequently  in  its  progress  through 
Europe.  It  will  be  unnecessary  to  make  the  repetition  here ;  it  is,  how- 
ever, important  that  the  fact  should  be  signalized,  that  during  the  pre- 
valence of  the  epidemic,  very  few  persons  in  the  city  were  entirely 
exempt  from  some  derangement  or  disorder  of  the  digestive  functions. 
It  is  not  probably  exaggeration  to  assert,  that  two-thii*ds  of  the  popula- 
tion were  affected  in  this  manner,  which  is  to  be  attributed  entirely  to 
the  epidemic  influences.  It  should  also  be  stated,  that  in  the  majority 
of  cases  which  assumed  the  decided  character  of  malignant  cholera,  pre- 
liminary symptoms  had  existed,  varying  in  duration  from  a  few  hours  to 
several  days.  In  those  rarer  instances  which  were  not  preceded  by  any 
premonitory  signs,  the  subjects  were  the  aged,  the  intemperate  indivi- 
duals, who  had  committed  some  great  imprudence  in  diet,  or  whose  con- 
stitution has  been  enfeebled,  and  such  cases  were  generally,  if  not  uni- 
versally, fatal. 

"  The  chief  mortality  of  the  disease  existed  in  the  public  institutions. 
It  was  much  lighter  in  private  practice.     The  following  Table  exhibits 


CHOLERA.  409 

the  cases  of  deaths,  as  reported  m  private  practice,  and  tlie  pubUc  in- 
stitutions. The  reports,  however,  do  not  exhibit  the  results  of  private 
practice  in  as  favourable  a  light  as  they  really  were.  A  considerable 
number  of  physicians  in  the  most  respectable  practice,  reported  only  the 
cases  that  proved  fatal,  or  exceedingly  severe.  They  did  not  return  to 
the  Board  of  Health  the  Hghter  cases,  which  yielded  to  the  operation  of 
remedial  measures.  The  mortality  of  private  practice  in  the  reports, 
appears,  in  consequence,  to  have  been  far  greater  than  it  really  was. 

''  Table  of  Cases  and  Deaths,  with  Ratio  as  occurring  in  Private  Prac- 
tice,  and  the  Public  histitutions. 


Cases. 

Deaths. 

Ratio  of  Deaths  to  Cases 

Private  Practice,     . 

.     1175     . 

.    270    . 

.     1  to  4  3-16 

Hospitals,      .     .     . 

.      874    . 

.    342    . 

.     lto2  5-9 

Aims  House,      .     . 

174    . 

.       92    . 

.     1  to  1  41-46 

Arch-street  Prison, 

86    . 

.      46     . 

.     1  to  1  20-23 

"  Had  the  returns  of  cases  in  private  practice  been  complete,  the 
proportion  of  cases  would  have  been  much  greater,  it  would  have 
ranged  probably  as  1  to  70  or  80,  or  even  more. 

"  In  the  hospital  practice,  the  first  cases  introduced  were  nearly  all 
fatal.  This  circumstance  is  to  be  accounted  for  from  the  univeral  ob- 
servation, wherever  cholera  has  prevailed  epidemically,  that  the  worst 
constitutions  were  the  first  to  suffer  attacks.  In  the  commencement  of 
the  epidemic,  persons  first  attacked,  unaware  of  their  danger,  and  the 
nature  of  the  affection,  neglect  application  for  aid,  and  resist  the  offer 
of  hospital  assistance  until  reduced  to  a  hopeless  condition.  Besides, 
misled  by  the  authority  of  the  English  and  Scotch  writers,  extensive 
means  had  been  prepared  for  warming  the  patients  by  heated  air,  steam, 
and  other  means.  Experience  in  a  short  time  proved  the  pernicious 
efiects  of  this  system.  The  patients  succumbed  most  rapidly  under 
the  exhaustion  induced  by  the  profuse  watery  exhalation  from  the  skin 
caused  by  this  treatment.''' 

Why  the  cholera,  if  an  imported  disease,  should  have  broken  out 
nearly  simultaneously  in  Quebec  and  Montreal,  is  very  easily  accounted 
for,  since  both  are  the  receptacles  of  British  and  other  foreign  emi- 
grants ;  on  the  same  principle,  we  must  explain  its  appearance  so  soon 
after  at  New  York,  where,  no  doubt,  it  arrived  by  a  separate  importation 
from  Europe — a  circumstance  which  will  prevent  us  from  feeling  the 
same  surprise  with  Dr.  Jackson,  that  between  Quebec  and  New  York 
all  the  intermediate  cities  on  the  sea  board  escaped,  at  least  for  a  few 
months.  This  is  analogous  to  the  exemption  of  Waterford  and  Wexford, 
during  several  months  that  cholera  raged  in  Dublin  and  Cork  :  I  gave 


410  CLINICAL   MEDICINE. 

Dr.  Jacksoii^s  Eeport  at  much  lengthy  because  it  is  intended  to  be  con- 
clusive against  the  theory  of  contagion;  while  it,  in  my  opinion,  con- 
tains strong  internal  evidence  of  a  contrary  tendency. 

In  the  United  States  cliolera  spread  far  and  near,  as  might  be  ex- 
pected from  the  wonderfully  rapid  and  frequent  intercourse  that  takes 
place  all  over  the  Union ;  but,  except  in  the  condensed  population  of 
the  chief  seaports,  its  ravages  were  not  great.  It  is  curious  to  observe 
how  little  Philadelphia  suffered  in  comparison  with  Montreal,  Quebec, 
or  New  York ;  no  doubt  because  its  population  is  less  condensed,  and 
live  in  families  more  separated  from  each  other.  In  making  this  ob- 
servation, I  do  not  mean  to  undervalue  the  power  of  predisposing 
causes,  such  as  poverty,  bad  diet,  intemperance,  &c.,  which  prevail  more 
in  the  latter  cities  than  in  Philadelphia.  Still,  comparing  America 
with  those  European  and  Asiatic  countries  which  suffered  most,  the 
only  constant  difference  we  can  discover  is,  that  the  separation  of  fami- 
lies is  much  more  complete  in  the  United  States  than  in  any  other 
country  except  England ;  and  to  this  difference,  consequently,  we  are 
justified  in  referring  for  an  explanation  of  the  remarkable  fact,  that 
England  and  the  United  States  fared  better  than  other  countries,  not- 
withstanding their  acknowledged  superiority,  above  all  in  the  facilities  of 
internal  communication.  A  wish  to  be  brief  forces  me  to  conclude  the 
subject  of  the  cholera  in  North  America  with  the  following  list  of  places, 
and  the  dates  of  its  arrival  in  each. 


Albany, 

.     3rd  July,  1832 

Troy, 

.     16th  July,  „ 

New  Brunswick,  . 

.        .    July, 

Rochester,     . 

.     July, 

Baltimore,    . 

.     August,       ,, 

Washington, 

.     August, 

Boston, 

.     August,*     „ 

Cholera  did  not  reach  South  America  at  all,  a  fact  explicable  by  the 
great  length  of  the  voyage  from  the  infected  countries,  which  reason  also 
protected  the  Cape  of  Good  Hope,  the  West  Indies,  and  New  Holland. 
It  is  a  curious  fact,  that  New  Holland,  for  the  same  reason,  has,  until 
.lately,  been  free  from  measles,  scarlatina,  and  hooping  cough,  although 
the  colony  is  fifty  years  old.  But  now  that  the  intercommunication 
between  it  and  other  parts  of  the  world  has  become  much  shorter  and 
more  frequent,  owing  to  the  rapid  spread  of  steam  navigation,  it  has 
been  visited  with  all  these  diseases. 

*  I  am  not  certain  of  the  dates  of  its  first  appearance  where  the  day  of  commencement 
is  not  mentioned  ;  but  in  all  the  above  places  the  cholera  prevailed  during  the  above 
months. 


CHOLERA.  411 

We  must  now  return  to  Europe  ;  and  first  with  respect  to  Portugal.  It 
appears  from  the  following  editorial  paragraph  in  the  Medical  Gazette,"^ 
tliat  the  disease  was  imported.  "  The  London  Merchant  Steamer 
sailed  from  England  for  Oporto,  on  the  25th  December,  1832,  and 
arrived  at  the  mouth  of  the  Douro  on  the  1st  January,  1833,  having 
lost  seven  persons  on  her  passage  by  cholera.  The  troops  which  she 
took  out,  with  General  Sohgnac,  landed  immediately  at  Eoz,  about  two 
miles  to  the  west  of  Oporto.  By  a  letter  from  a  medical  gentleman  of 
that  city,  which  we  have  lately  seen,  it  appears  that  cases  of  the 
disease  occurred  at  Eoz,  on  the  road  to,  and  in  Oporto,  before  the 
15th  of  January;  and  we  know  from  other  authorities,  that  it  has  since 
spread  to  Coimbra  on  the  south,  and  Vigo  on  the  north.^' 

Mr.  Lardner,  a  very  intelligent  surgeon,  and  formerly  a  pupil  of 
mine,  has  written  a  very  interesting  paper  on  the  progress  of  cholera 
in  Portugal. — Lancet,  1834-5,  p.  314.  He  is  a  decided  non-conta- 
gionist,  but  his  facts  seem  to  me  to  be  strongly  corroborative  of  the 
doctrine  of  contagion.  Among  other  admissions,  the  following  is  al- 
most conclusive.  "Lisbon  was  not  visited  by  cholera  for  a  consi- 
derable time  after  Aveiro ;  which  fact  may  give  the  contagionist  a  lift, 
for  during  the  siege  there  existed  no  direct  communication  by  water 
between  Oporto  and  Lisbon.  The  Miguelite  batteries  would  not  allow 
a  ship  to  enter  the  Tagus,  and  Donna  Marians  ships  kept  a  strict 
blockade  outside  the  bar."  The  epidemic  took  six  months  to  travel 
slowly  by  land  from  Oporto  to  Lisbon.  Had  the  communication  by 
sea  between  these  two  ports  been  open,  no  doubt  it  would  have  reached 
Lisbon  sooner  :  in  America  how  quickly  it  extended  from  one  seaport 
to  another. 

It  is  a  remarkable  circumstance,  and  one  which  ought  to  have  great 
weight  in  the  discussion  respecting  the  contagiousness  of  cholera,  that 
cliolera  has  in  no  recorded  instance  appeared  in  any  place  sooner  than 
the  ordinary  modes  of  communication  might  have  brought  it  from  some 
infected  station.  Again,  it  can  easily  be  proved  that  the  rate  at  which 
cholera  travels  varies  with  the  rapidity  of  that  communication.  A  few 
weeks  were  sufficient  to  transport  it  from  the  ports  of  Britain  more 
than  three  thousand  miles  across  the  Atlantic  to  Canada,  while  it  took 
six  months  to  creep  along  the  interrupted  line  of  communication  between 
Oporto  and  Lisbon. 

Prom  the  preceding  observations  it  will  appear,  1st,  that  cholera  has 
had  no  fixed  rate  of  progress ;  2d,  that  it  has  spread  in  every  direction, 
sometimes  northwards,  sometimes  southwards,  and  other  times  east  and 

*  Vol.  xii.  p.  123. 


4ia  CLINICAL  MEDICINE. 

west,  its  route  being  determined  not  by  the  points  of  the  compass,  but 
by  the  great  lines  of  internal  and  international  communication. 

Cholera  never  got  to  any  of  the  West  Indian  islands,  nor  to  British 
(formerly  Dutch)  Guiana,  Demerara,  nor  any  of  the  embouchures  of 
the  great  South  American  rivers,  Amazon,  Orinoco,  or  La  Plata, 
though  the  soil  and  climate,  with  the  immense  tracts  of  inun- 
dated and  swampy  lands,  would  there  seem  most  favourable  to  its 
development. 

In  September,  1835,  (Lancet,  vol.  for  1834-5,  p.  782,)  "  the  cholera 
had  nearly  ceased  its  ravages  in  the  South  of  France,  and  took  a  south 
and  easterly  direction  along  the  countries  bordering  the  Mediterranean 
Sea.  It  penetrated  into  Piedmont  in  spite  of  the  strictest  pre- 
cautions, and  prevailed  with  more  or  less  intensity  at  Nice,  Coni,  Li- 
vorno,  Genoa,  Plorence.  From  this  extract  we  do  not  learn  the 
dates  of  its  arrival  at  the  above  places,  but  they  were  probably  ac- 
cording to  their  respective  distances  from  France.  The  kingdom  of 
Naples  was  not  infected  until  a  still  later  period;  at  Naples,  pro- 
bably, September,  1836.  It  attained  the  maximum  at  Naples  on  the 
22nd  November,  1836;  Algiers,  14th  October,  1837  ;  Bona,  Septem- 
ber, 1837. 

To  trace  it  accurately,  its  secondary  routes  and  dates  of  reappearance 
should  be  made  out ;  it  would  then  be  found  to  have  returned  often  on 
its  steps. 

Thus  in  September,  1837,  Marseilles  was  attacked  for  the  third  time, 
while  in  the  same  season  of  the  year  1837,  it  reappeared  also  at 
Berlin,  Prague,  and  Dantzic. 

It  is  worthy  of  remark,  that  cholera  began  at  Naples,  which  carries 
on  a  perpetual  commercial  intercourse  with  Marseilles,  about  a  year 
before  it  commenced  in  Rome  !  August,  1837.  The  disease  travelled 
southwards  in  the  north  of  Italy,  setting  out  from  France ;  northwards 
in  the  south  of  Italy,  starting  from  Naples. 

Since  the  year  1838,  cholera  ceased  to  be  heard  of  in  any  part  of 
Europe,  if  we  except  an  isolated  case  or  two  occasionally  reported  in  the 
medical  journals,  and  which  were  probably  nothing  more  than  aggravated 
attacks  of  English  cholera ;  but  in  the  latter  part  of  1847  it  again  made 
its  appearance  in  the  eastern  parts  of  Russia,  from  whence,  however, 
owing,  I  suppose,  to  the  strict  precautionary  measures  which  were  at 
once  adopted,  it  has  disappeared  without  spreading  farther  west.  I  shall 
now  shortly  trace  the  origin  and  course  of  this  epidemic,  with  which  we 
may  yet  be  visited ;  for  as  I  have  shown  you  in  my  last  lecture,  the 
epidemic  which  appeared  in  Moscow  in  September,  ]  830,  did  not  reach 
England  until  November,  1831. 


CHOLERA.  413 

"  Some  time  in  the  early  part  of  1843,^  Cholera  appeared  iu  the  north- 
ern parts  of  Burmah,  and,  passing  in  a  southerly  direction,  committed 
great  ravages,  and  caused  great  consternation,  at  Ava  and  Ameerapoora. 
After  traversing  these  cities,  it  passed  down  towards  Eangoon,  pursuing 
the  course  of  the  Irrawaddy  and  its  tributaries,  and  attacking  cliiefly, 
according  to  Burraan  report,  the  towns  and  villages  situated  on  the 
banks  of  these  rivers.  Still  pursuing  a  southerly  course,  in  August  it 
appeared  in  the  Burmese  town  of  Martaban,  situated  on  the  junction  of 
three  great  rivers — the  Salween,  the  Attaran,  and  the  Gyne,  and  nearly 
opposite  to  the  British  settlement  of  Moulmein.  In  September  it  ap- 
peared in  Moulmein,  and  continued  to  prevail,  with  greater  or  less 
violence,  till  July,  1843,  when  it  disappeared,  although  an  isolated  case 
was  occasionally  seen  during  the  two  following  years.  Soon  after  its 
entrance  into  Moulmein,  it  was  reported  to  have  appeared  in  the  villages 
to  the  south,  on  the  banks  of  the  Salween,  and  on  the  sea-side,  and  then, 
still  travelling  due  south,  it  reached  in  November  the  second  principal 
Burman  town,  Tavoy.  Tavoy  is  a  place  of  considerable  size,  and  is 
situated  about  150  miles  south  of  Moulmein,  on  the  bank  of  a  broad 
shallow  stream,  loaded  with  debris  from  the  neighbouring  mountains. 
Cholera  raged  here  with  great  fury  for  three  or  four  months,  and  then 
gradually  disappeared.  Soon  after  entering  Tavoy  it  was  heard  of  in  the 
villages  round  the  city,  and  travelling  south,  it  showed  itself  shortly 
afterwards  (some  time  in  January  1843)  in  Mergui,  the  third  principal 
town  in  the  provinces,  situated  on  a  small  island  formed  by  two  branches 
of  the  Tenasserim  river,  opening  into  the  Bay  of  Bengal,  about  150  miles 
to  the  south  of  Tavoy .''^ 

It  prevailed  throughout  the  Indian  Provinces  at  intervals  during  the 
next  two  years,  and  early  in  1845  it  raged  with  great  violence  along  the 
banks  of  the  Indus,  and  also  in  Affghanistan.  Thence  it  spread  into 
Persia,  Tartary,  Ilindostan,  and  the  pachalick  of  Bagdad.  In  May  1846, 
it  broke  out  with  frightful  severity  at  Teheran,  carrying  off  as  many  as 
300  a-day  for  several  weeks,  and  reducing  the  population  of  that  town 
by  at  least  20,000  souls. 

Prom  this  town  it  proceeded  in  two  directions,  one  south  west  in 
the  line  of  Ispahan,  Shiraz,  and  Bagdad;  and  the  other  N.  W.  to  Ta- 
breez.  In  October  some  cases  occurred  at  Saliam  and  Lankeram,  frontier 
Trans-caucasian  towns  of  Russia.  In  the  south  it  spread  along  the 
Tigris ;  and  in  December  it  raged  with  great  violence  at  Mecca,  "  being 
supjjosed  to  have  been  conveyed  thither  by  the  jpilgrims froyn  Bagdad'^ 
Early  in  the  year  1847,  it  appeared  to  the  west  of  the  Caucasus,  in  the 

«  Researches,  &c,,  by  E.  A,  Parkes,  M.D.,  1847,  p.  158. 


414  CLINICAL    MEDICINE. 

liussian  army  fighting  against  the  Circassians.  "  By  the  middle  of  May, 
it  was  at  Tiflis  and  also  at  Astrakan  at  the  mouth  of  the  Volga ;  and 
where  it  reached  its  greatest  intensity  about  the  end  of  July.  The  towns 
of  Kars  and  Kutais  also,  lying  westward  of  Erivan  and  Tiilis,  with  many 
of  the  surrounding  villages,  were  attacked  about  the  same  time.  In 
August  it  broke  out  at  Batoum  on  the  eastern  shore  of  the  Black  Sea, 
and  soon  afterwards  at  Erzeroum  and  Trebizonde,  to  the  southward ; 
reaching  the  last-named  city  about  the  9th  of  September.  Shortly  before 
this  time,  it  had  appeared  at  Taganrog,  Kertsch,  Mariopol,  and  other 
towns  on  the  Sea  of  AzofP,  and  near  the  mouth  of  the  Don ;  subsequently 
spreading  in  a  northerly  direction  towards  the  more  inland  provinces  of 
Charcow,  Kiev,  &c.  Again,  were  all  the  most  stringent  preventive 
measures  found  to  be  utterly  ineffectual  in  arresting,  or  even  in  slacken- 
ing, the  progress  of  the  disease.  By  the  Russian  official  reports  in  the 
middle  of  September,  we  learned  that  it  was  gradually  spreading  more 
and  more  into  the  heart  of  the  empire,  by  two  distinct  lines ;  one  more 
northerly  and  along  the  course  of  the  Volga  towards  Saratoff,  Tamboff, 
Kasan,  Toula,  and  Moscow ;  and  the  other  from  the  north  shores  of  the 
Black  Sea  along  the  lines  of  the  Don  and  Dnieper,  and  their  numerous 
branches.  The  general  direction  of  the  epidemic  has  been  north-west- 
ward ;  and  it  has  been  remarked  that  the  route,  followed  in  the  present 
year,  has  been  very  nearly  that  along  which  the  '  disease-producing  some- 
thing' travelled  in  1831.  On  the  last  day  of  September,  it  appeared  at 
Moscow,  and  about  the  same  time  at  Odessa  and  at  Perecop,  on  the 
north-western  shores  of  the  Black  Sea,  having  previously  ceased,  or  nearly 
so,  at  Taganrog,  Mariopol,  and  other  parts  to  the  eastward.  In  the 
middle  of  October,  we  were  told  by  official  returns  that,  without  counting 
Georgia,  the  Caucasus,  and  the  country  of  the  Cossacks  of  the  Black  Sea, 
the  disease  existed  with  greater  or  less  severity  in  sixteen  different  govern- 
ments of  the  Russian  empire.  At  the  same  time  it  was  announced  that 
it  had  again  broken  out  in  some  parts  of  the  north  of  Persia,  as  Tabreez, 
Khoi,  &c.,  and  also  at  Bagdad. 

''  In  the  second  week  of  November,  the  St.  Petersburg  Gazette  stated 
that  *  the  most  western  points  the  cholera  has  yet  reached,  are  the  town 
of  Alexandrof  in  the  government  of  Kherson,  and  the  district  of  Olgapol 
in  PodoHa,'  which  is  not  above  thirty  miles  from  the  Austrian  frontier. 
To  the  northward,  it  had  been  travelHng  from  Moscow  to  Novgorod  in 
the  direction  of  the  capital,  and  also  in  a  course  nearly  due  west  to 
Dwinaberg,  at  a  very  httle  distance  from  Riga,  and  within  forty 
miles  of  the  Prussian  territory.  A  letter  from  Vienna  of  the  20th  ult. 
announced  that  some  cases  had  occurred  in  the  circle  of  Tarnapol  in 
Gallicia." 


CHOLEllA.  415 

This  latter  extract  I  have  taken  from  a  pamphlet  published  by  Dr. 
Gavin  Milroy  of  London,  which  contains  an  excellent  concise  history  of 
the  cholera  epidemic. 

The  next  account  which  we  have  of  this  epidemic,  I  read  from  the 
Russian  Cholera  Gazette  of  January  29th,  1 848.  Dr.  Thielmann  writing 
in  it,  says — "During  the  month  of  December  the  severe  cold  so  com- 
pletely arrested  the  progress  of  Asiatic  cholera,  that  there  was  reason  to 
believe  it  would  disappear  entirely.  It  has  altogether  ceased  in  the  pro- 
vinces around  the  Caspian  ;  and  with  the  exception  of  Moscow,  Mohilew, 
and  Witepsk,  it  is  no  longer  met  with  in  any  of  the  great  cities  or  towns 
of  the  empire.  Even  in  these,  and  in  smaller  places,  the  disease  has 
assumed  so  mild  a  character,  that  it  appears  to  be  on  the  point  of 
extinction. 

"  Letters  from  Constantinople  of  the  1st  January  announce  the  gra- 
dual disappearance  of  cholera  in  that  city.  The  epidemic  was  then 
chiefly  confined  to  the  Arsenal ;  and  out  of  210  attacked,  only  58  died. 
Accounts  from  Bagdad  of  the  7th  of  December  state  that  the  cholera 
had  almost  entirely  disappeared  from  Kerkoula  and  Suleymania.  Letters 
from  Mossol,  dated  the  12th  of  December,  mention  that  the  cholera  had 
ceased  in  that  city,  after  having  killed  300  persons;  and  intelligence 
from  Aleppo  of  the  18th,  states  that  it  has  appeared  at  Beregik,  on 
the  banks  of  the  Euphrates,  and  was  causing  from  ten  to  fifteen  deaths 
daily  .'^ 

Then,  as  in  the  previous  epidemic,  it  was,  however,  only  smouldering 
to  break  out,  ere  long,  wdth  greater  fury,  and  probably  pursue  the  same 
route  it  did  in  1831-32  ;  for,  according  to  an  official  account  received 
in  the  beginning  of  June  of  this  year  (1848),  there  had  been  no  fewer  than 
three  hundred  thousand  persons  attacked,  of  whom  one  hundred  thou- 
sand perished,  and  the  proportion  of  persons  attacked  was  to  the  popula- 
tion nearly  as  great  as  on  the  former  visitation.  Its  progress  was  in  all 
respects  similar  to  that  of  1832,  when  it  abated  on  the  occurrence  of  the 
frost,  and  re-appeared  in  the  Spring,  and  proceeded  onwards.  It  had 
declared  itself  at  Nijui-Novgorod,  and  at  Moscow.  At  Moscow  there 
were  twelve  cases  and  five  deaths  between  the  8th  of  April  and  12th  of 
May ;  and  at  Novgorod,  twenty -two  cases  and  twelve  deaths  between 
the  17th  and  24th  of  April. 

Let  me  now,  before  concluding,  call  your  attention  to  some  points  in 
the  treatment  of  this  contagious  pestilence.  When  cholera  existed  in 
DubHn  in  the  spring  of  1832,  the  modes  of  treatment  principally  relied 
on  were,  bleeding  in  violent  spasmodic  cases,  emetics  of  ipecacuanha  and 
mustard,  the  application  of  heat  externally,  and  internally  stimulants, 
but,  above  all,  calomel,  not  in  small  but  in  large  and  frequently  repeated 


416  CLINICAL   MEDICINE. 

doseSj  either  alone  or  combined  with  opium.  I  need  not  tell  you  that 
the  mercurial  treatment  came  to  us  sanctioned  by  high  authority  :  it  was 
a  remedy  to  which  the  experience  of  Indian  practitioners  had  given  a 
high  character,  but  in  our  hands,  I  must  say,  it  proved  of  very  little 
value.  Be  this  as  it  may,  I  must  say  that  I  had  reason  to  be  dissatisfied 
with  this  mode  of  treatment ;  I  had  tried  it  myself,  and  had  seen  it  tried 
in  every  way  which  ingenuity  or  experience  could  suggest,  but  I  had 
seen  it  fail  almost  in  every  instance. 

About  the  middle  of  summer  the  epidemic  began  to  spread  fearfully 
among  those  who  had  hitherto  been  exempt  from  its  attacks ;  many 
persons  in  respectable  life  were  seized,  and  my  private  practice  afforded 
numerous  opportunities  of  becoming  practically  acquainted  with  the 
disease.  In  several  cases  to  which  I  was  called  in,  the  malady  had  not 
advanced  to  the  stage  of  collapse,  the  symptoms  of  cholera,  properly 
so  called,  had  merely  commenced,  the  intensity  of  the  disease  was  still 
far  aw^ay,  and  a  fair  chance  was  afforded  for  the  operation  of  therapeutic 
agents.  In  most  instances  I  tried  calomel  and  all  the  ordinary  reme- 
dies with  profitless  results ;  my  treatment  proved  too  often  ineffectual ; 
and  some  persons,  whose  lives  I  highly  valued,  perished  in  spite  of  all 
my  efforts,  leaving  me  grieved  for  their  loss,  and  mortified  by  my  own 
want  of  success.  I  found  that  I  could  no  longer  place  any  confidence 
in  calomel,  and  determined,  in  my  o\^ti  mind,  to  give  up  a  remedy  which 
had  so  signally  failed ;  it  was,  however,  a  question  of  deep  anxiety  to 
me  what  I  should  select  instead,  or  to  what  article  in  the  Materia 
Medica  I  should  have  recourse,  where  so  many  had  proved  utterly 
valueless. 

About  this  time  I  happened  to  be  called  on  to  attend  a  case  of  ob- 
stinate diarrhoea  with  the  late  Dr.  Hunt.  The  case  was  an  extremely 
harassing  one,  and  had  resisted  all  the  ordinary  remedies.  I  advised 
the  use  of  acetate  of  lead  and  opium  in  full  doses ;  this  was  given, 
and  I  had  the  satisfaction  of  finding  that  the  diarrhoea  soon  yielded. 
Before  tliis  period  I  had  received  a  letter  from  that  able  practitioner  and 
excellent  man.  Dr.  Bardsley,  of  Manchester,  directing  my  attention  to 
the  use  of  acetate  of  lead  in  large  doses  in  that  form  of  diarrhoea  which 
occurs  towards  the  termination  of  long  fevers,  that  is  to  say,  the 
diarrhoea  which  precedes  and  accompanies  inflammation  of  the  glands 
of  the  small  intestines.  I  had  subsequently,  at  Sir  Patrick  Dun's 
Hospital,  several  opportunities  of  witnessing  the  truth  of  Dr.  Bardsley's 
remarks.  I  saw  that,  in  many  cases  during  the  course  of  fever,  where 
the  patient  was  low  and  prostrated,  symptoms  of  intestinal  congestion 
came  on,  followed  by  diarrhoea,  w^hich  many  persons  thought  would  end 
in  ulceration  of  the  glands  of  Peyer ;  and  I  found  that  in  such  cases 


TREATMENT    OF    CHOLERA.  417 

the  acetate  of  lead  was  the  only  remedy  that  could  be  relied  on.  I  ob- 
served^ too,  that,  contrary  to  the  prevailing  opinion  on  the  subject,  it 
could  be  given  in  large  doses  with  perfect  safety.  You  are  aware  that 
Dr.  Bardsley  has  shown  that  it  may  be  given  to  children  in  very  con- 
siderable doses  without  any  bad  effects,  and  that  in  adults  he  has  pushed 
this  remedy  to  the  extent  of  twenty  or  thirty  grains  in  the  day,  without 
any  unfavourable  consequences. 

With  these  impressions  I  came  to  the  resolution  of  trying  the  ace- 
tate of  lead  in  the  next  case  of  cholera  which  offered  a  chance  of  de- 
riving benefit  from  any  kind  of  treatment.  It  is  known  that  there  are 
some  cases  in  which  the  disease  at  once  assumes  so  frightful  a  malig- 
nity, that  the  patient  is  lost  from  the  very  moment  of  his  seizure. 
Tliis  hopeless  and  intractable  malignity  is  not  peculiar  to  cholera ;  it  is 
seen,  in  fever,  scarlatina,  croup,  measles,  and  hydrocephalus ;  in  fact, 
there  are  certain  forms  of  all  diseases  in  which  the  best  directed  efforts 
of  medical  skill  not  only  fail  in  curing  the  disease,  but  even  in  retard- 
ing its  progress.  But  there  are  cases  of  cholera  where  the  patient  is 
not  struck  down  at  once,  where  the  disease  is  not  developed  at  once  in 
all  its  awful  intensity,  and  where  time,  brief  though  the  space  may  be, 
is  allowed  for  the  play  of  therapeutic  agencies.  It  is  in  such  cases  the 
acetate  of  lead  may  be  given  with  some  prospect  of  success,  and  it  is 
by  sucli  cases  alone,  and  not  by  those  which  are  necessarily  fatal  ah 
initio,  that  its  value  is  to  be  tested. 

Before  we  proceed  further,  I  may  observe,  that  the  principle  on  which 
the  calomel  treatment  w^as  employed  in  cholera  arose  from  almost  con- 
stantly observing  that  there  was  a  total  deficiency  of  bile  in  the  stools. 
Soon  after  the  supervention  of  an  attack,  the  alvine  discharges  were  ob- 
served to  be  white  and  without  the  slightest  tinge  of  bile ;  and  on  this 
very  remarkable  symptom  practitioners  dwelt  almost  exclusively,  think- 
ing that  the  patients  only  chance  lay  in  restoring  the  secretion  of  the 
liver.  Now  it  is  obvious  that  the  absence  of  bile  in  the  stools  is  no 
more  a  cause  of  the  disease  than  is  the  deficiency  of  urea  in  the  kid- 
neys or  of  serum  in  the  blood.  Yiewing  the  disease  in  this  light,  it 
would  be  just  as  reasonable  to  give  a  diuretic  to  restore  the  secretion  of 
the  kidneys,  as  to  give  calomel  to  produce  a  flow  of  bile.  The  liver 
ceases  to  secrete,  not  only  in  consequence  of  the  injury  done  to  its  vi- 
tality by  the  proximate  cause  of  cholera,  whatever  that  may  be,  but  also 
from  a  mechanical  cause,  namely,  from  a  diminution  in  its  supply  of 
blood. 

It  may  appear  strange  that  when  the  same  given  number  of  vessels 
go  to  the  liver  and  come  from  it  at  all  times,  that  the  quantity  of  blood 
circulating  in  it  should  be  greater  at  one  time  than  another.     I  liave 

VOL.  I.  27 


418  CLINICAL   MEDICINE. 

not  time  at  present  to  enter  fully  into  this  subject ;  but  it  is  a  fact  ad- 
mitting of  sufficient  proof,  that  the  quantity  of  blood  circulating  in 
any  organ  is  very  much  modified  by  the  state  of  its  capillaries.  The 
quantity  of  blood  also  which  goes  to  a  gland  varies  according  to  the 
peculiar  state  of  that  gland,  being  greater  during  its  period  of  active 
secretion  than  when  it  is  at  rest.  But  in  a  case  of  cholera,  where  the 
capillary  vessels  of  the  intestinal  canal  from  the  stomach  to  the  rec- 
tum are  actively  engaged  in  taking  up  the  serum  from  the  whole  mass 
of  blood,  and  pouring  it  into  the  cavity  of  the  digestive  tube,  there  is 
an  enormous  drainage  from  the  system,  and  there  must  be,  consequently, 
a  deficiency  of  blood  somewhere.  Now  it  would  appear  that  a  quantity 
of  blood,  sufficient  for  the  purposes  of  secretion,  is  abstracted,  not  only 
from  the  biliary,  but  also  from  the  urinary  system ;  and  hence  it  ap- 
pears just  as  reasonable  to  give  diuretics  to  restore  the  urinary  secretion, 
as  to  give  calomel  to  excite  the  secretion  of  the  liver.  It  would  be, 
a  priori,  as  original  a  mode  of  treatment,  and  be  equally  as  successful. 
I  have  therefore  no  hesitation  in  saying,  that  the  calomel  treatment  has 
no  claim  to  merit  on  the  ground  of  theory,  and,  as  far  as  I  have  ob- 
served of  it  in  this  country,  it  seems  to  be  of  no  practical  value  in  the 
treatment  of  cholera. 

With  regard  to  the  quantity  of  acetate  of  lead  which  may  be  given 
in  this  disease,  and  the  mode  of  administering  it,  a  few  words  are  ne- 
cessary. I  have  abeady  stated,  that  when  I  first  tried  it,  I  prescribed 
it  in  large  doses,  fortified  by  the  authority  of  Dr.  Bardsley,  and  by  my 
own  experience,  of  its  utility  in  many  cases  of  diarrhoea.  It  appears, 
that  before  I  recommended  the  acetate  of  lead,  it  had  been  used  at  the 
Cholera  Hospital  in  Grangegorman-lane.  Of  this  I  was  not  aware, 
until  a  book  was  subsequently  published  by  Dr.  Cranfield,  which  I  after- 
wards reviewed  in  the  sixth  volume  of  the  Dubhn  Journal  of  Medical 
Science,  and  I  feel  that  on  that  occasion  I  did  fair  and  impartial  justice 
to  its  merits.  I  certainly  did  not  know  that  the  acetate  of  lead  had 
been  given  at  the  Grangegorman  Hospital ;  for,  in  the  very  able  report 
of  cholera,  as  observed  at  that  institution,  published  by  one  of  its  offi- 
cers, Mr.  M'Coy,  the  treatment  relied  upon  appears  to  have  been  the 
mercurial,  and  not  a  word  was  said  of  acetate  of  lead.  It  had  been 
used  there  by  one  physician ;  but  it  was  given  in  small  doses,  insuffi- 
cient to  produce  decided  efi'ects,  and  no  stress  had  been  laid  on  its  value 
as  a  remedy  in  cholera  by  the  practitioners  attached  to  the  hospital. 
Be  this  as  it  may,  acetate  of  lead  was  not  known  to  the  medical  men  of 
Dublin,  and  to  the  practising  apothecaries,  before  I  recommended  it. 
It  had  been  frequently  employed  in  the  form  of  injection  by  them ; 
but  no  one  had  given  it  in  large  doses  by  the  mouth,  or  introduced 


TREATMENT  OF  CHOLERA.  419 

it  to  the  notice  of  the  profession.  I  believe  I  can  fairly  claim  the 
merit,  such  as  it  is,  of  being  the  first  to  give  it  in  large  and  efiTectual 
doses. 

The  mode  in  which  I  administered  it  was  this  : — a  scruple  of  the 
acetate  of  lead,  combined  with  a  grain  of  opium,  was  divided  into 
twelve  pills,  and  of  these,  one  was  given  every  half  hour,  until  the  rice 
water  discharges  from  the  stomach  and  rectum  began  to  diminish.  In 
all  cases  where  medicine  promised  any  chance  of  relief,  this  remedy 
was  attended  with  the  very  best  effects.  It  gradually  checked  the 
serous  discharges  from  the  bowels,  and  stopped  the  vomiting.  I  need 
not  say  of  what  importance  this  is :  as  long  as  these  exhausting  dis- 
charges continue,  as  long  as  the  serum  of  the  entire  body  continues  to 
be  drained  off  by  the  intestinal  exhalants,  what  hope  can  we  entertain  ? 
What  benefit  can  be  expected  from  calomel  and  stimulants,  when  every 
function  of  the  digestive  mucous  membrane  seems  to  be  totally  extin- 
guished, except  that  of  exhalation,  and  while  profuse  discharges,  occur- 
ring every  five  or  ten  minutes,  are  reducing  the  patient  to  a  state  of 
alarming  prostration?  Knowing  the  inevitable  fatality  of  all  cases 
where  these  discharges  went  on  unchecked,  I  was  happy  at  having  dis- 
covered a  remedy  which  seemed  to  possess  more  power  in  arresting 
them  than  any  yet  devised,  and  this  impression  was  confirmed  by  the 
results  of  subsequent  experience. 

That  the  acetate  of  lead  will  succeed  where  all  other  astringents  fail, 
was  proved  by  the  case  of  Mr.  Parr,  of  this  hospital.  Having  got  an 
attack  of  threatening  diarrhoea,  at  a  time  when  cholera  was  prevailing 
in  Dubhn,  this  gentleman  used  various  kinds  of  astringents,  and  took 
so  large  a  quantity  of  opiates,  that  he  became  quite  narcotized,  but 
without  any  relief  to  his  symptoms.  When  I  saw  him  he  was  as  bad  as 
ever,  and  was  beginning  to  exhibit  appearances  of  collapse,  I  advised 
the  use  of  piUs,  composed  of  acetate  of  lead  and  opium,  in  the  pro- 
portions already  mentioned,  and  had  the  satisfactian  of  finding,  that 
before  night  the  diarrhoea  had  ceased.  The  pills  are  to  be  used  one 
every  half  hour  while  the  diarrhoea  remains  unchecked,  but  as  it 
begins  to  diminish,  the  intervals  between  each  pill  may  be  prolonged, 
and  in  this  way  the  patient  may  be  gradually  prepared  for  leaving 
off  the  remedy  altogether.  I  have  frequently  given  in  this  way  as 
much  as  forty  grains  of  acetate  of  lead  in  twenty-four  hours,  with 
great  advantage  to  the  patient,  and  without  any  bad  consequences 
ensuing. 

It  is  unnecessary  for  me  to  say  any  more  on  this  subject ;  if  I  chose 
to  mention  names,  I  could  bring  forward  the  names  of  many  medical 
men  in  Dublin,  whose  lives,  I  am  happy  to  state,  were  saved  by  the 


420  CLINICAL   MEDICmE. 

use  of  this  remedy.  I  may,  however,  observe,  that  this  mode  of  treat- 
ment has  now  become  universal  here,  and  that  it  has  almost  completely 
superseded  the  use  of  calomel  and  opium.  I  will  confess  that  tliis  fact 
is  a  source  of  high  gratification  to  me,  and  I  point  also  with  pleasure 
to  the  fact,  that  since  it  became  extensively  known,  (as  it  did  during 
the  last  invasion  of  the  epidemic),  the  profession  has  gained  more 
credit  than  before,  and  the  number  of  cures  has  been  proportionally 
greater. 

I  may  remark  that  the  most  convenient  way  of  making  the  pills  is  to 
add  five  or  six  grains  of  powdered  liquorice  to  the  scruple  of  acetate  of 
lead,  and  mixing  into  a  mass  by  means  of  mucilage  of  gum-arabic. 
Year  after  year  since  I  first  made  public  the  value  of  this  plan  of  treat- 
ment in  cholera,  I  have  received  the  most  gratifying  letters  as  to  its  suc- 
cessful employment  from  practitioners  in  India.  The  following  observ- 
ations of  Dr.  Parkes,  who  had  the  opportunity  of  witnessing  two  recent 
outbreaks  of  cholera  in  India  in  1843  and  1845,  while  serving  as 
assistant-surgeon  in  one  of  H.  M.  regiments,  I  look  on  as  most  valuable 
testimony.  I  quote  from  his  Essay  on  Cholera,  to  which  I  have  already 
referred.     At  page  207  he  says  : — 

"  Of  all  the  astringents  which  have  been  used  in  cholera,  none  has 
appeared  to  me  so  efficacious  as  the  one  recommended  by  Dr.  Graves, 
viz.,  the  acetate  of  lead.  It  is  true  that  it  did  not  arrest  the  purging 
in  aU  cases,  but  it  possessed  this  great  advantage,  that  in  the  form  of  pill 
with  opium,  it  did  not  seem  to  increase  the  irritabihty  of  the  stomach, 
but  rather  to  aUay  it.  I  used  to  give  two  or  three  grains  with  a  quar- 
ter of  a  grain  of  opium,  every  half  hour  for  the  first  two  or  three  hours, 
and  then  every  hour  for  a  variable  period  according  to  the  intensity  of 
the  case.  It  was  often  found  that  the  vomiting  first  ceased,  and  then 
the  purging ;  the  algide  symptoms  were  of  course  unaltered,  but,  as 
already  said,  no  remedy  yet  known  possesses  any  influence  over  them, 
and  it  is  the  best  way  to  leave  them  altogether  to  themselves,  and  take 
the  chance  of  their  not  advancing  to  their  fuU  extent.  The  only  bad 
effect  I  ever  noticed  after  the  employment  of  these  large  doses  of  lead, 
was  subacute  gastritis ;  but  this  is  a  comparatively  trifling  aff'air,  and 
can  generally  be  overcome  by  relays  of  leeches  to  the  epigastrium 
during  the  period  of  reaction.^' 

Dr.  Thom,  Surgeon  of  the  86  th  regiment,  in  an  account  of  the 
cholera  as  it  affected  that  regiment  at  Kurrachee  in  1846,  thus  speaks 
of  the  combination  : — 

"  The  acetate  of  lead,  in  doses  of  one,  two,  or  three  grains,  and  one- 
eighth  of  a  grain  of  acetate  of  morphia,  was  employed  to  stop  those 
profuse  watery  dejections  which  continued  in  some  cases  after  reaction 


TREATMENT  OF  CHOLERA. 


421 


had  taken  place ;  and  in  this  point  of  view  it  was  a  most  useful  remedy. 
Of  course  in  those  cases  where  vomiting  and  purging  are  the  first  symp- 
tomsj  and  collapse  appears  to  be  their  consequence,  the  early  use  of  this 
remedy  was  resorted  to,  and  with  very  good  encouragement.'^"^ 


Medical  Times,  1847,  vol.  xvi.  p.  151. 


422 


LECTUEE  XXIX. 


INFLTJENZA. 


I  ADVERTED  in  the  two  last  lectures  to  the  subject  of  influenza,  and 
endeavoured  to  point  out  some  of  the  principal  features  in  which  epi- 
demics diiffer,  as  to  their  mode  of  spreading,  from  diseases  which  owe 
their  diffusion  chiefly  to  contagion.  I  stated  that  contagious  disorders 
were  comparatively  slow  in  their  progress,  attacking  different  masses  of 
the  population  in  succession,  and  exhibiting,  in  general,  a  tendency  to 
affect  distinct  classes  of  the  community  at  different  periods.  On  the 
other  hand,  when  an  epidemic  hke  influenza  makes  its  appearance,  every 
thing  comes  under  its  influence  almost  simultaneously,  and  like  a  cloud 
it  overshadows  the  whole  country  in  the  space  of  a  few  weeks.  Such 
was  the  course  of  the  epidemics  of  1847  and  1837,  and  so  it  was  with 
the  influenza  of  1782,  which  travelled  from  the  east,  and  left  traces 
of  its  ravages  in  almost  every  quarter  of  the  globe. 

In  the  case  of  epidemics  which  traverse  the  whole,  or  nearly  the 
whole  extent  of  the  inhabited  portion  of  the  earth,  it  would  be  a  mat- 
ter of  great  interest  to  ascertain  the  place  of  their  first  appearance,  or 
their  point  of  departure.  The  cholera,  as  I  have  already  shown  you, 
commenced  in  Hindostan,  and  in  its  route  followed  the  great  lines  of 
communication  and  commerce  :  its  general  progress  has  been  northwest ; 
but  in  Portugal,  Spain,  and  Italy,  it  has  travelled  in  various  directions, 
its  progress,  however,  being  in  general  along  the  great  lines  of  com- 
munication leading  from  the  part  of  the  frontier  where  it  first  broke 
out,  towards  the  large  towns  in  the  interior.  It  is  probable  that  influ- 
enza pursues  some  certain  and  uniform  course,  independent  of  the  phy- 
sical circumstances  which  retarded,  accelerated,  or  stopped  the  progress 
of  Asiatic  cholera.  It  is  likely,  too,  that  its  rate  of  spreading  is  sub- 
ject to  fewer  variations.  Cholera  took  years  to  accomplish  its  journey 
from  Hindostan  to  Britain  :  but,  once  established  there,  it  crossed  the 
Atlantic  at  a  single  step.     The  march  of  influenza  has  not  as  yet  been 


INFLUENZA.  423 

mapped  out ;  from  the  accouuts  which  have  reached  us  in  1837,  it  seems 
to  liave  travelled  at  the  same  time  iii  very  different  directions,  arriving 
at  Cape  Town  in  January,  during  mid-summer,  and  in  London  in  the 
same  month,  during  mid-winter ;  while  it  is  reported  to  have  reached 
New  Holland,  and  to  have  raged  among  our  antipodes,  two  months 
earlier,  and  in  1847  it  pursued  the  same  variable  course. 

It  is  obvious  that  influenza  does  not  depend  upon  mere  variations  of 
temperature,  for  we  have  had  many  seasons  as  changeable  as  the  present, 
without  the  occurrence  of  any  such  epidemic.  Besides,  influenza  is 
known  to  be  a  disease  which  travels  through  the  most  difijerent  cHmates, 
preserving  its  peculiar  character  and  identity  in  all.  It  is  not  to  be 
supposed  that  the  same  temperature,  or  the  same  barometrical  and  hy- 
grometrical  conditions  of  the  atmosphere,  prevail  here  as  in  Spain, 
France,  Germany,  or  Sweden ;  yet  in  all  these  countries  the  influenza 
has  exhibited  an  uniformity  of  character,  and  an  identity  of  type,  prov- 
ing beyond  all  doubt  that  it  is  one  and  the  same  disease.  That  influenza 
is  not  produced  by  a  low  temperature,  is  proved  by  the  occurrence  of 
the  disease  in  the  month  of  June,  in  that  of  1762;  and  in  the  months 
of  May  and  June,  in  that  of  1782;  as  well  as  by  its  appearance 
at  the  Cape  of  Good  Hope  in  the  middle  of  summer,  as  I  have 
already  noticed.  In  1837  influenza  increased  rapidly  in  tliis  city,  while 
tlie  weather  was  remarkable  for  its  serenity  and  agreeable  mildness. 
In  London,  many  were  led,  by  a  limited  view  of  the  subject,  to  con- 
sider its  origin  as  connected  with  the  breaking  up  of  the  frost,  and  the 
peculiar  state  of  atmosphere  attending  a  general  thaw.  Influenza  is 
not  influenced  in  its  progress  by  situation  or  locality ;  it  does  not  creep 
along  the  shores,  or  follow  the  course  of  large  rivers,  or  select  low 
marshy  districts,  in  preference  to  drier  and  more  elevated  soils. 

From  what  has  been  said,  it  is  obvious  that  influenza  does  not  depend 
upon  vicissitudes  of  temperature,  peculiarities  of  situation,  or  supposed 
moist  or  dry  states  of  the  atmosphere ;  neither  does  it  arise  from  the 
prevalence  of  certain  wdnds,  for  meteorological  observation  furnishes 
many  instances  of  the  prevalence  of  such  winds  without  any  influenza ; 
and,  on  the  other  hand,  it  frequently  travels  against  the  wind.  The 
same  views  are  also  advocated  by  the  late  Dr.  Holland ;  at  page  184  of 
his  "  Medical  Notes  and  Eeflections,^^  he  says,  '^  It  is  true  that  some 
authors,  and  in  concurrence  with  common  opinion,  have  attributed  these 
epidemics  solely  to  atmospheric  changes,  and  the  influence  of  extraordi- 
nary seasons  upon  the  human  body.  And  it  must  be  admitted,  on  behalf 
of  this  opinion,  that  certain  of  the  seasons  during  which  they  have  pre- 
vailed, have  been  remarkable  and  anomalous  ;  and  further,  that  in  com- 
mon catarrh  arising  from  obvious  causes  of  atmospheric  change,  many 


424  CLINICAL   MEDICINE. 

of  the  symptoms  resemble  the  lighter  and  more  transient  forms  of  the 
disorder  in  question.  But  there  is  something  manifestly  beyond  this 
relation,  and  independent  of  it.  A  disease  which  has  appeared  and  spread 
at  different  seasons,  in  the  middle  of  summer  as  well  as  in  the  depth  of 
winter ;  which  has  been  found  traversing  whole  continents,  continuing 
this  course  through  many  successive  months,  and  often  assuming  even  a 
definite  direction  of  progress,  which  affects  contiguous  places  in  different 
degrees,  and  at  different  times ;  which  frequently  continues  in  the  same 
place  for  several  weeks  or  months,  under  every  appreciable  variety  of 
atmospheric  state;  and  which  often  affects,  almost  simultaneously,  large 
masses  of  people  living  on  the  same  spot,  while  others  in  adjoining 
localities  are  exempt ;  such  disease  cannot  be  considered  as  due  to  any 
of  the  known  qualities  or  variations  of  the  atmosphere,  to  which  the  term 
weather  is  applied.''^ 

It  is  probable  that  influenza  may  depend  chiefly  on  telluric  influence — 
upon  some  agency  connected  with  variations  in  the  physical  conditions 
which  operate  on  the  external  surface  of  our  planet ;  but  on  this  point 
we  can  only  speak  conjecturally,  in  the  present  state  of  our  knowledge, 
and  we  should  not  allow  ourselves  to  lapse  into  mere  speculative  and 
fruitless  disquisitions.  How  often  the  variations  to  which  I  have 
alluded  occur,  and  whether  they  are  subject  to  any  general  law,  remains 
yet  to  be  determined.  Several  epidemics  of  this  description  have  been 
distinctly  recorded  in  the  eighteenth  century,  viz.  in  1708, 1712,  1728, 
1733,  1743,1758,  1762,  1767,  1775,  1782,  1788,  1789;  while  in 
the  portion  of  the  nineteenth  century  already  elapsed,  five  influenzas  have 
occurred,  viz.,  in  1803,  1831,  1833,  1837,  and  1847.  This  list  is  as 
complete  as  our  medical  annals  will  permit  us  to  make  it,  but  still  we 
caimot  rely  on  it  as  including  all  the  epidemics  of  this  nature  which  have 
occurred  during  the  last  one  hundred  and  forty-seven  years.  Supposing 
it  correct,  it  would  indicate  the  average  return  of  influenza  once  every 
ten  years. 

In  making  calculations  of  this  kind,  medical  writers  should  always 
take  care  not  to  confound  influenza,  a  disease  which  spreads  rapidly 
over  the  whole  globe,  regardless  of  season  and  climate,  with  those  local 
catarrhal  affections  that  occur  in  all  temperate  climates  almost  annually. 
One  thing,  at  least,  is  certain  with  respect  to  this  disease,  that  it  does 
not  arise  from  exposure  to  cold,  or,  as  it  is  termed,  from  catching  cold. 
This  I  have  repeatedly  observed.  Persons  who  took  the  best  care  of 
themselves,  who  always  went  warmly  clothed,  and  were  never  exposed 
to  the  inclemency  of  the  weather,  took  the  disease  just  as  readily  as  the 
half-clad  labourer,  who  had  to  undergo  daily  exposure  to  all  the  vicissi- 
tudes of  our  changeful  climate.     But  it  should  be  observed,  that  al- 


INFLUENZA.  425 

though  the  attack  of  influenza  in  any  individual  was  not  necessanly  de- 
pendent on  exposure  to  cold,  yet  in  many  instances  it  was  evident  that 
catching  cold  determined  the  immediate  access  of  influenza,  or  increased 
its  violence  when  present. 

I  have  also  observed,  that  it  seldom  attacked  persons  labouring  under 
acute  diseases,  until  the  period  of  convalescence  arrived,  when  their  im- 
munity ceased,  and  they  became  just  as  liable  to  its  invasion  as  others. 
Thus  patients  labouring  under  typhus  escaped  as  long  as  the  fever  con- 
tinued ;  but  frequently,  on  the  very  day  the  crisis  occurred,  and  symp- 
toms of  returning  convalescence  appeared,  they  were  seized  with  influ- 
enza. This  is  a  very  unfortunate  circumstance.  Just  as  a  patient  had 
struggled  through  a  fever  of  seventeen,  nineteen,  or  twenty-one  days,  he 
was  attacked  with  a  new  and  dangerous  malady,  which  again  placed  him 
in  a  situation  of  imminent  danger. 

You  must  have  observed,  that  influenza  does  not  appear  in  every  in- 
dividual with  the  same  violence,  or  exhibit  in  all,  symptoms  identical  in 
their  intensity  or  duration.  As  in  most  other  epidemics  which  afl'ect 
society  at  large,  the  different  constitutions  and  ages  of  the  individuals, 
and  the  different  states  in  which  the  morbid  influence  finds  them,  modify 
greatly  the  nature  of  the  attack ;  so  that,  although  a  vast  number  are 
affected,  they  suffer  in  very  different  degrees,  and  the  complaint  exhibits 
every  variety  of  shade,  from  simple  coryza,  or  catarrh,  requiring  no 
treatment,  to  catarrhal  fever  of  the  worst  and  most  unmanageable  de- 
scription. Many  persons  laboured  under  what  would  be  termed  a  com- 
mon cold,  were  it  not  from  the  extreme  frequency  of  such  symptoms, 
combined  with  other  circumstances  which  mark  the  nature  of  the  dis- 
ease. The  same  thing  was  observed  with  respect  to  cholera :  few  per- 
sons, during  the  prevalence  of  cholera,  escaped  without  undergoing 
some  form  of  bowel  attack,  but  the  mode  and  character  of  such  attacks 
varied  very  remarkably.  • 

Influenza  is  not  by  any  means  so  severe  or  so  rapidly  fatal  a  disease 
as  cholera,  but  the  mortality  which  it  has  produced  is  greater,  as  it 
affects  almost  every  person  in  society,  while  the  ravages  of  cholera  were 
comparatively  limited.  Consequently,  although  the  proportion  of  deaths 
among  a  given  number  of  individuals  attacked  was  greater  in  cholera, 
the  mortality  for  society  at  large  is  much  greater  in  influenza.  In 
Dublin  it  is  extremely  difficult  to  obtain  any  thing  like  exact  statistical 
details  of  the  comparative  mortality  at  different  periods,  for  no  general 
registry  of  deaths  is  kept  in  this  city.  The  nearest  result  to  truth  that 
can  be  determined  is  from  the  number  of  interments  in  the  two  chief 
cemeteries  of  the  city,  at  Glasnevin  and  at  Harold's  Cross.  The  latter 
was  not  long  opened  when  the  epidemic  prevailed  in  Ireland  in  1837, 


426  CLINICAL   MEDICINE. 

but  I  obtained  the  following  return  from  tlie  former,  which  exhibits  tlie 
number  of  interments  for  the  months  of  January  and  February,  1837, 
and  for  the  corresponding  months  of  the  previous  year.  I  also  give 
the  return  for  the  months  before  and  after  the  influenza. 


In  December, 

1835    . 

.  355 

In  December, 

1836    . 

.  413 

January, 

1836    . 

.  392 

January, 

1837    . 

.  821 

February, 

1836    . 

.  362 

February, 

1837    . 

.  537 

March, 

1836    . 

.  392 

March, 

1837     . 

.  477 

Total  for  four  months  1501  2248 

Increase  during  Influenza,  747. 

Assuming,  then,  that  in  Prospect  Cemetery  alone,  about  seven  hun- 
dred persons  were  buried  who  died  of  influenza,  and  that  there  were 
at  least  three  times  as  many  persons  buried  in  the  other  church-yards 
of  the  city  and  suburbs,  we  may  conclude  that  in  Dublin  alone  more 
than  four  thousand  people  died  of  the  influenza  in  1837,  not  taking 
into  account  the  greater  number  who,  although  they  got  over  the  im- 
mediate attack  of  the  epidemic,  sank  afterwards  under  various  diseases, 
of  which  influenza  had  laid  the  foundation.  In  Paris  the  same  epidemic 
influenza  caused  likewise  a  great  mortality ;  for  it  appears  from  a  state- 
ment in  the  Eevue  Medicale,  that  the  average  daily  mortality,  during 
the  first  fifteen  days  of  Pebruary,  amounted  to  one  hundred  and  ten, 
which  is  more  than  double  the  usual  average.  This  only  refers  to  per- 
sons dying  in  their  own  houses,  and  does  not  include  the  deaths  in  the 
hospitals.  Eighteen  thousand  die  in  private  houses  annually  in  Paris — 
i.  e.,  on  an  average  about  fifty  daily.  The  rate  varies  from  twenty  to 
seventeen  a  day,  according  to  the  season ;  but  during  the  first  fifteen 
days  of  Pebruary,  it  rose  from  fifty-eight  to  one  hundred  and  fifty-two 
in  the  day. 

I  have  obtained  a  similar  return  to  that  of  1837,  for  the  months  of 
December,  1847,  and  January,  1848,  being  the  months  in  which  the 
late  epidemic  of  influenza  prevailed  in  Dublin ;  it  is  as  follows  : — 

Prospect  Cemetery y  Glasnevin. 


1846,  November 

.    571 

1847,  November 

.     697 

December 

.    867 

December 

.  1141 

1847,  January 

.    756 

1848,  January 

.     912 

February 

.    700 

February 

.    786 

Total  for  four  months  2894  3535 

Increase  during  Influenza,  642. 

This  return  does  not  include  those  who  died  in  the  fever  sheds  and 


INFLUENZA.  427 

North  Union  Workhouse,  amounting  to  215  in  the  month  of  Decem- 
ber, 1848,  alone,  and  many  of  which  were  doubtless  cases  of  influenza; 
but  by  omitting  them,  we  avoid  the  increased  mortality  caused  by  the 
epidemic  of  fever  which  then  raged,  and  thus  obtain  a  nearer  approxi- 
mation to  the  truth. 

Tliis  return  was  most  kindly  furnished  to  me  by  Mathias  J.  O'Kelly, 
Esq.,  the  present  Secretary  of  the  Cemetery  Company.  To  it  I  am 
enabled  to  add  a  similar  return  from  Mount-Jerome  Cemetery,  Harold's 
Cross  :  very  few  poor  persons  are  interred  in  this  cemetery. 


In  November, 

1846    . 

.    55 

In  November,  1847    . 

.     66 

December, 

1846    . 

.  113 

December,  1847     . 

.  124 

January, 

1847    . 

.     90 

January      1848     . 

.  104 

February, 

1847    . 

.    74 

February,    1848     . 

.    72 

Total  for  four  months  332  366 

Increase  during  Influenza,  34. 

Influenza  in  1837  was  very  fatal  where  it  attacked  persons  who  had 
been  subject  to  chronic  bronchitis,  or  who  had  happened  to  labour 
under  any  form  of  asthmatic  affection ;  for  this,  I  confess,  I  was  not 
quite  prepared.  And  when  first  called  to  attend  asthmatic  persons 
labouring  under  influenza,  I  expected  that,  from  being  accustomed  to 
periodic  attacks  of  dyspnoea  and  cough,  they  would  be  better  qualified 
to  bear  the  disease,  and  would  continue  to  exhibit  that  tenacity  of  life 
for  which  asthmatic  persons  are  so  remarkable.  The  old  also  suffered 
considerably ;  but  some  very  old  persons  had  extremely  severe  attacks 
of  influenza,  and  yet  escaped.  I  attended,  along  with  Mr.  Maurice 
Collis,  the  venerable  Judge  Day,  the  cotemporary  of  Goldsmith,  who, 
at  the  age  of  ninety-three,  had  sufficient  strength  of  constitution  to 
shake  off  a  most  violent  seizure.  Two  gentlemen,  who  had  fought  at 
the  battle  of  Bunker's  Hill,  also  survived  the  disease  in  a  severe  form ; 
but,  generally  speaking,  it  was  very  fatal  among  the  aged.  Influenza 
was  also  very  fatal  among  persons  who  laboured  under  disease  of  the 
heart ;  and  in  this  instance  age  made  no  difference  as  to  result,  for  the 
young  and  old  were  equally  liable  to  danger.  I  have  also  seen  it  fatal 
in  cases  of  deformity  of  the  chest,  from  curvature  of  the  spine,  and 
other  causes.  The  mortality  was  also  very  great  among  persons  in  ad- 
vanced life  who  laboured  under  tussis  senilis  :  in  a  word,  all  persons 
labouring  under  pulmonary  irritation,  or  weakness,  were  exposed  to 
very  considerable  danger.  Subsequent  experience  has  proved  also,  that 
where  influenza  left  behind  an  obstinate  and  irritating  cough,  and  where 
the  constitution  had  a  scrofulous  taint,  the  disease  was  very  apt  to  pass 


428 


CLINICAL   MEDICINE. 


into  tubercular  plitliisis.  Among  all  the  families  I  know,  but  two 
escaped  the  influenza  altogether :  one  consisted  of  eleven  children,  be- 
sides the  parents  and  servants,  and  resided  in  Pill-lane,  in  the  very 
centre  of  the  city ;  the  other  family  consisted  of  five  females,  advanced 
in  life,  and  who  lived  in  one  of  the  fashionable  streets. 

Very  nearly  similar  remarks  apply  to  the  influenza  of  1847,  but  the 
depression  of  the  powers  of  life  was,  I  think,  much  more  marked, 
while  the  feverish  symptoms  were  less  than  in  1837.  Consonant  with 
this  observation  I  remarked  that  death  occurred  with  symptoms  of 
^mralysis  of  the  lungs  in  all  the  cases  which  I  saw  that  terminated 
fatally:  this  appeared  to  be  the  manner  in  which  the  peculiarly  depressing 
influence  of  the  epidemic  was  manifested. 

Allow  me  to  digress  here  for  a  moment,  for  the  purpose  of  making 
one  observation,  which  a  review  of  several  cases  of  influenza,  attended 
with  severe  pulmonary  symptoms,  suggests  to  me.  It  is  a  common 
error  in  pathology  to  confound  effects  with  causes,  and  where  the  cause 
of  a  disease  is  not,  and  probably  cannot  be  known,  to  fix  on  some 
peculiar  and  leading  symptom,  and  to  attribute  to  it  the  origin  of  all 
the  rest.  But  it  is  quite  illogical  to  say  that  one  symptom  is  the  cause 
of  another,  or  that  because  it  has  the  precedence,  it  should  also  have 
the  initiative.  I  alluded  to  this  error  in  a  former  lecture,  when  speaking 
on  the  pathology  of  scarlatina.  It  has  been  over  and  over  again  as- 
serted, that  the  dropsy  of  scarlatina  arises  from  the  previous  inflam- 
matory affection  of  the  skin,  or  subcutaneous  tissues ;  and  the  same 
thing  has  been  asserted  with  regard  to  the  desquamation  of  the  cuticle. 
But  I  have  brought  forward  facts  and  arguments  to  prove  that  this 
opinion  is  not  founded  in  truth,  and  that  dropsy,  as  well  as  desquama- 
tion of  the  cuticle,  may  take  place  where  there  has  been  no  eruption 
whatever,  and  not  the  least  trace  of  cutaneous  or  subcutaneous  inflam- 
mation. 

Now  when  a  person,  after  exposure  to  cold,  gets  pneumonia  or  bron- 
chitis, followed  by  anasarca,  it  is  quite  a  common  tiling  to  hear  it  said, 
that  the  anasarca  had  its  origin  in  the  pulmonary  affection,  and  that 
the  effusion  of  serum  depended  on  obstructed  transmission  of  blood 
through  the  lung.  The  same  mode  of  explanation  has  been  applied  to 
disease  of  the  heart  as  the  cause  of  dropsy.  This  explanation,  however, 
appears  to  me  inadequate  and  unsatisfactory.  Many  cases  of  influenza 
were  accompanied  by  extreme  congestion  of  the  lungs,  and  consequently 
imperfect  aeration  of  the  blood  ;  and  yet  I  have  not  in  a  single  instance 
noticed  the  occurrence  of  dropsy  as  an  immediate  or  remote  conse- 
quence. Were  dropsy  dependant  on  the  state  of  the  lung  to  which  I 
have  alluded,  it  would  have  shown  itself  in  some  cases  at  least ;  and  yet 


INFLUENZA.  429 

I  have  seen  individuals  attacked  with  influenza  labouring  under  orthop- 
noea  and  severe  pulmonary  symptoms  for  weeks,  without  observing,  in 
any  instance,  the  slightest  anasarca  or  oedema.  In  one  case,  indeed, 
that  I  saw,  an  old  gentleman  at  Rathmines,  the  feet  and  legs  were  much 
swollen ;  but  this  I  attributed  to  his  having  remained  so  many  days  and 
nights  in  his  chair,  unable  to  lie  down.  This  has  strongly  impressed 
upon  my  mind  the  conviction,  that  when  dropsy  comes  on  after  disease 
of  the  lung,  that  the  one  is  not  always  the  consequence  of  the  other,  but 
that  both  often  result  from  the  same  cause,  and  owe  their  origin  to  the 
same  morbid  impression  on  the  system.  This  error  has  been  further 
confirmed  by  the  results  of  treatment,  practitioners  having  found  that 
measures  adapted  to  remove  congestion  of  the  lung  tended  also  to  remove 
the  dropsy ;  forgetting  here,  that  where  two  symptoms  closely  allied  arise 
together  from  the  same  cause,  you  will  be  most  likely  to  remove  both 
by  those  means  which  are  effectual  in  removing  either.  The  principle 
which  I  have  here  briefly  alluded  to,  will  apply  to  many  other  combina- 
tions of  disease ;  it  is  one  of  general  application,  and,  in  my  mind,  of  no 
ordinary  importance. 

The  epidemic  of  1837  differed  in  many  points  from  that  which  pre- 
vailed about  three  years  previously.  The  influenza  of  1833-4  was  by 
no  means  so  generally  fatal  as  then  and  in  1847.  It  was  characterised, 
like  both,  by  considerable  irritation  of  the  tracheal  and  bronchial  mucous 
membrane,  but  not  by  the  severe  bronchitis  and  pneumonia  which  have 
been  witnessed  in  later  cases  of  the  epidemic.  The  former  raged  in 
Dublin  chiefly  during  the  months  of  March  and  April.  It  came  on  very 
suddenly,  with  rapid  pulse,  hot  skin,  great  prostration,  languor,  and  ex- 
cessive sweating ;  there  were  cough,  coryza,  and  not  unfrequently,  vomit- 
ing at  the  commencement.  One  of  the  most  prominent  symptoms,  how- 
ever, was  headache,  which  was  excessively  severe.  There  was  also, 
cceteris paribus,  more  debility,  and  the  patients  did  not  bear  bleeding  so 
well  as  they  did  in  1837.  But  the  most  material  point  in  which  they 
differed  was  the  comparative  mortaKty.  The  disease  in  1 834  carried  off 
some  very  suddenly  with  cerebral  symptoms,  and  proved  fatal  to  others 
from  oppression  of  the  chest  and  dyspnoea.  Tew,  however,  died,  who 
survived  for  a  week  after  they  had  been  attacked,  and  the  disease 
rarely  left  behind  it  a  cough  at  all  approaching  in  violence  and  ob- 
stinacy to  that  which  in  the  later  epidemics  harassed  convalescents. 
On  the  whole,  the  fever  accompanying  the  influenza  of  1834  was 
more  acute,  and  set  in  with  more  marked  depression  of  the  nervous 
system,  and  the  disease  was  much  less  liable  to  become  chronic. 

It  would  conduce  greatly  to  the  advantage  of  medical  science,  if  a 
brief  and  accurate  history  was  left  to  posterity  of  the  character,  symp- 


430  CLINICAL   MEDICINE. 

toms,  pathological  phenomena,  and  treatment  of  every  epidemic.  Such 
a  record  would  prove  a  guide  and  beacon  to  the  practitioners  of  future 
ages — would  enable  them  to  draw  important  comparisons  between  the 
existing  and  the  past — and  thus  arrive  at  a  more  fixed  and  available 
knowledge  of  the  nature  and  habits  of  epidemic  complaints. 

There  are,  I  have  no  doubt,  many  curious  forms  of  epidemic  disease 
which  pass  through  society  either  wholly  unnoticed,  or  confounded  with 
others  to  which  they  have  some  slight  affinity.  I  think  I  have  seen 
particular  forms  of  scarlatina,  measles,  small-pox,  and  fever,  which  have 
not  been  accurately  noted,  although  they  prevailed  as  epidemics.  If 
every  form  of  epidemic  was  noted,  and  the  order  of  its  succession 
marked,  it  would  remain  to  be  ascertained  by  posterity  whether  there 
may  not  be  what  may  be  termed  cycles  of  epidemics,  and  whether  dis- 
ease, after  having  manifested  itself  in  determinate  forms,  following  each 
other  in  determinate  succession,  may  not  commence  again  after  the 
lapse  of  a  certain  number  of  years,  and  pursue  the  same  course.  This 
is  not  impossible,  if  we  suppose  that  epidemics  are  connected  with  tel- 
luric or  electrical  influences,  which  are  now  known  to  observe  a  periodic 
course.  Were  this  ascertained,  a  sort  of  observatory  of  epidemics 
could  be  easily  established  in  the  various  civilised  states. 

In  treating  of  the  nature  of  influenza,  it  will  be  proper  to  consider, 
in  the  first  place,  the  general  constitutional  symptoms  which  attend  it, 
and  afterwards  glance  at  those  which  are  chiefly  of  a  local  description. 
In  some  cases  of  influenza,  there  is  little  or  no  fever,  as  in  the  last  epi- 
demic ;  neither  does  the  presence  of  fever  seem  essential  to  the  more 
severe  or  even  fatal  cases,  although,  generally  speaking,  fever  occupied 
a  very  prominent  position  among  the  group  of  symptoms  by  which  the 
disease  was  characterized  in  1837.  I  have  seen  cases  in  which  there 
was  nothing  like  regular  fever  from  beginning  to  end,  and  yet  which 
terminated  fatally. 

I  remember  treating  two  patients  who  had  been  labouring  under  or- 
thopnoea  for  ten  days,  and  yet  in  these  patients  the  skin  was  cool,  the 
pulse  in  general  soft,  and  very  little  above  the  normal  standard,  and  the 
tongue,  though  furred,  quite  moist ;  but  so  great  was  the  distress  of 
respiration,  that  they  were  obhged  to  remain  sitting  up  in  bed  night 
and  day,  panting  for  breath.  This,  however,  was  the  exception  with 
respect  to  severe  cases  in  1837,  the  majority  being  attended  with  very 
considerable  fever.  In  the  shght  cases  the  fever  was  scarcely  perceived, 
or  altogether  absent ;  as  was  the  case  with  myself  and  some  of  my 
friends.  We  had  coryza,  hoarseness,  cough,  and  some  degree  of  pul- 
monary irritation,  without  any  fever.  At  first,  I  thought  that  fever 
was  an  essential  part  of  the  disease ;  but  the  cases  to  which  I  have 


INFLUENZA.  43] 

alluded,  and  others  of  a  similar  kind,  have  convinced  me  that  this  is 
not  the  fact — a  conviction  fully  ratified  by  the  late  influenza. 

Where  the  fever  appeared,  it  came  on  with  the  usual  symptoms  of 
pyrexia — namely,  sense  of  chilliness,  particularly  about  the  small  of  the 
back,  without  decided  rigors,  flying  pains  in  the  limbs  and  joints,  and 
headache,  generally  referred  to  the  situation  of  the  frontal  sinus.  There 
were  from  the  commencement,  great  restlessness,  jactitation,  and  more 
or  less  insomnia.  Sickness  of  the  stomach,  loss  of  appetite,  and  ten- 
dency to  diarrhoea,  were  also  common  symptoms.  The  skin  was  in 
general  hot,  and  without  any  tendency  to  moisture,  although,  in  some 
cases,  there  were  occasional  perspirations.  These,  however,  were  sel- 
dom general  or  regular,  and  lasted  only  for  a  few  hours.  The  pulse  was 
accelerated  and  tolerably  full,  occasionally  even  hard  and  wiry.  These 
symptoms  were  very  subject  to  slight  exacerbations  and  remissions,  and 
seldom  continued  the  same  for  more  than  twelve  hours  together. 
Where  the  disease  existed  for  any  length  of  time  in  a  violent  form,  the 
tongue  usually  became  furred  and  loaded,  the  patient  lost  all  relish  for 
food,  and  in  many  cases  complained  of  harassing  thirst. 

In  severe  cases,  the  most  prominent  symptoms  were  cough,  wheezing, 
restlessness,  dyspnoea,  and  loss  of  sleep.  The  appetite  was  in  gene- 
ral more  or  less  impaired ;  but  I  have  seen  some  severe  cases  in  which 
it  did  not  fail  remarkably  for  several  days ;  the  restlessness  and  jacti- 
tation attended  many  cases  throughout.  You  are  not,  however,  to 
suppose,  that  this  always  depended  on  the  presence  of  pain  or  fever. 
The  headache  was  not  in  all  severe  or  distressing  j  and  I  have  already 
stated,  that  the  fever  was  not  so  general  or  so  violent  as  one  would 
suppose.  The  loss  of  sleep  depended  upon  derangement  in  the  tone  of 
the  nervous  system,  independent  of  fever;  for  I  have  observed  it  in 
numerous  patients,  in  whom  scarcely  any  febrile  excitement  was  observ- 
able ;  but  when  complicated  with  fever,  both  react  upon  and  aggravate 
each  other.  The  skin,  where  fever  was  present,  was  hot :  this  heat  was  in- 
terrupted by  occasional  perspirations,  which,  however,  did  not  give  much 
relief,  or  tend  to  diminish  the  amount  of  increased  temperature.  Some- 
times the  skin  was  hot,  and  at  the  same  time  bedewed  with  perspi- 
ration during  the  whole  course  of  the  disease;  but  this  was  rather 
unusual. 

The  pulse,  in  influenza,  is  seldom  the  same  throughout ;  one  time  you 
will  find  it  quick  and  rather  hard;  in  six  hours  afterwards  it  will  be  quick 
and  soft ;  in  six  or  eight  hours  more  it  will  appear  as  if  about  to  fall  to 
the  normal  standard ;  and  next  day  you  will  find  it  quick  and  jerking 
again.  These  changes  are  accompanied  by  corresponding  alterations  in 
the  temperature  and  humidity  of  the  skin.     But  what  is  most  remark- 


432  CLINICAL   MEDICINE. 

able  with  regard  to  the  pulse  is^  that  it  sometimes  becomes  full,  and 
rather  strong  and  wiry  towards  the  termination  of  the  disease;  and 
this  you  will  observe  in  patients  who  have  been  suffering  for  days^  or 
even  weeks. 

I  attended  with  the  late  Mr.  CoUes,  a  gentleman  in  Castle-street, 
aged  sixty,  of  a  full  habit,  and  subject  to  attacks  of  dyspnoea  and  cough 
during  winter.  This  gentleman  was  attacked  with  influenza,  ushered  in 
and  accompanied  by  severe  fever ;  and  it  was  observed,  that  as  the  dis- 
ease advanced,  his  pulse  became  fuller  and  stronger,  so  that  it  was  thought 
advisable  to  bleed  him.  He  was  bled  with  apparent  relief,  and  the  blood 
was  extensively  bufPed  and  cupped.  This  phenomenon  I  have  observed 
in  every  case  attended  with  fever,  and  indeed  in  some  where  no  appre- 
ciable fever  existed.  Thus,  a  gentleman  in  Dame-street,  who  had  no 
fever,  and  who  merely  laboured  under  teazing  cough,  distress  of  respira- 
tion, and  oppression  of  the  chest,  the  blood  on  being  drawn,  exhibited 
very  distinct  buffing  and  cupping.  The  same  thing  happened  in  the 
case  of  a  gentleman  in  Dominick-street,  whom  I  ordered  to  be  blooded 
under  exactly  the  same  circumstances. 

The  gentleman  in  Castle-street,  whom  I  attended  with  Mr.  Colles, 
exhibited  a  very  curious  state  of  pulse.  In  him,  as  in  many  others,  the 
pulse  was  extremely  variable  as  to  its  strength,  being  at  one  time  hard 
and  firm,  and  at  another  soft  and  weak.  If  you  were  to  visit  him  in  the 
morning,  from  the  feel  of  the  pulse  you  would  be  inclined  to  give  him 
stimulants ;  if  you  saw  him  for  the  first  time  on  the  evening  of  the  same 
day,  you  would  think  venesection  indispensable.  This  gentleman^s  state 
was  hopeless ;  he  laboured  under  great  suffering,  dyspnoea,  and  inability 
to  cough  up  the  viscid  mucous  secretion,  and  yet  his  pulse  was  both 
strong  and  firm.  Mr.  Colles,  whose  attention  I  directed  to  the  state  of 
the  pulse,  observed,  that  were  he  to  feel  it  without  seeing  the  patient, 
or  knowing  his  previous  liistory,  he  would  be  greatly  inclined  to  bleed 
him  immediately.  I  have  adverted  in  a  former  lecture  to  this  state  of 
the  pulse,  as  connected  with  irritation  of  the  nervous  system,  rather  than 
with  any  inflammatory  state  of  the  constitution  in  general ;  and,  there- 
fore, I  shall  not  now  recur  to  the  subject  further,  than  to  remark,  that 
I  have  never  observed  any  disease  in  which  the  pulse  formed  so  bad  a 
guide  as  to  the  propriety  of  venesection  as  in  influenza.  In  some  cases, 
venesection  was  most  useful,  although  the  pulse  was  in  every  respect 
natural ;  in  others,  it  could  not  be  borne  even  to  the  smallest  amount, 
although  the  pulse  was  hard  and  wiry.  Neither  was  the  state  of  blood 
an  unerring  guide ;  for  even  in  those  who  sank  rapidly  from  the  debili- 
tating effects  of  moderate  bleeding,  the  blood  was  very  much  cupped  and 
buffed. 


INFLUENZA.  433 

"  The  most  important  question/'  says  Dr.  Holland,  "  in  the  treatment 
in  influenza  doubtless  regards  the  extent  to  which  antiphlogistic  means 
may  be  carried,  or  the  fitness  of  employing  them  at  all.  And  the  point 
as  to  bleeding  is  that  which  stands  foremost  here,  and  has  chiefly  embar- 
rassed all  practitioners.  The  most  general  precept  on  this  subject  is 
liable  to  exceptions ;  but  collecting  what  on  the  whole  is  safest  and 
most  expedient,  it  must  be  one  which  forbids  bleeding  as  an  ordinary 
practice  in  this  disorder.  The  adynamic  type  throughout  in  the  greater 
number  of  cases ;  the  singular  disproportion  in  all  between  the  seeming 
severity  of  the  inflammatory  symptoms  and  their  real  slightness  or  nul- 
lity; the  actual  failure  of  bleeding  in  mitigating  the  violent  and  painful 
cough  which  seems  most  expressly  to  require  it ;  and  the  frequent  suc- 
cess of  remedies  precisely  the  reverse  of  this ;  all  show  a  specialty  in 
the  disease,  to  which  we  must  refer,  more  or  less  directly  in  every 
question  of  practice.  Whatever  the  cause  or  precise  seat  of  irritation, 
it  is  certain  that  it  has  rarely  the  character  of  true  membranous  inflam- 
mation. In  truth,  the  same  reasons  which  prevent  or  Kmit  bleeding  in 
hooping-cough,  apply  no  less  to  the  peculiar  cough  and  irritation  of 
the  influenza.  We  have  rarely  any  authority  for  it  in  the  state  of  the 
pulse,  wiiich  neither  in  strength  nor  frequency  bears  relation  to  these 
inflammatory  symptoms ;  while  the  difiicult  or  painful  respiration,  which 
often  suggests  the  remedy,  furnishes  evidence  against  its  fitness  by  be- 
coming frequently  more  laborious  than  before — the  effect  of  larger  ac- 
cumulation in  the  bronchial  cells,  and  of  diminished  power." 

I  shall  now  mention  the  particulars  of  a  very  remarkable  case  which 
came  recently  under  my  notice.  I  was  called  to  visit  a  lady,  somewhat 
advanced  in  life,  but  of  a  good  constitution,  and  labouring  under  the 
ordinary  form  of  influenza,  with  considerable  dyspnoea  and  cough.  In 
the  course  of  eight  or  nine  days  her  symptoms  began  to  decline ;  she 
got  up,  and  seemed  convalescent.  As  the  cough  and  pulmonary  irri- 
tation still  prevailed  to  a  certain  extent,  it  was  thought  advisable  not  to 
allow  her  to  eat  meat,  but  she  obtained  leave  to  take  some  fresh  had- 
dock. After  dinner,  her  cough  becoming  more  troublesome  than  be- 
fore, she  had  frequent  recourse  to  a  stale  and  rancid  cough-bottle, 
containing  squill  and  ipecacuanha.  During  the  evening  and  night  she 
felt  her  dinner  like  an  undigested  load,  and  her  stomach  turned.  She 
vomited,  and  was  purged  and  griped  incessantly,  until  I  saw  her  next 
day.  On  the  third  day,  the  medicines  I  had  ordered  moderated  the 
purging,  but  the  nausea  and  occasional  vomiting  continued.  On  the 
fourth  day,  the  purging  had  entirely  ceased,  but  the  sickness  of  stomach 
persisted.  I  sought  to  appease  this  by  the  ordinary  means,  which  fail- 
ing, I  examined  her  Avith  care  on  the  following  day,  and  discovered  a 

VOL.  I.  28 


434  CLINICAL    MEDICINE. 

strangulated  hernia.  At  this  time  the  pulse  had  scarcely  risen  above 
the  natural  standard.  Mr.  Cusack  operated  that  night  with  his  usual 
skill,  and  all  the  symptoms  depending  on  incarcerated  hernia  ceased. 
But  they  had  scarcely  disappeared,  when  the  pulmonary  symptoms,  and 
the  copious  secretion  from  the  bronchial  tubes  recurred,  and  she  did 
not  survive  this  relapse  of  the  influenza  more  than  a  few  days. 

This  is  an  instructive  example  of  an  insidious  combination  of  circum- 
stances very  likely  to  mislead  a  practitioner ;  for  as  the  vomiting  was 
for  a  day  or  two  accompanied  by  a  looseness  of  the  bowels,  the  suspicion 
of  hernia  would  not  strike  the  attention.  It  is  plain  that  in  this  case 
indigestion  produced  an  increased  and  morbid  activity  in  the  motions  of 
the  alimentary  canal,  which  led  to  the  incarceration  of  the  portion  of 
gut.  Up  to  a  certain  moment  the  symptoms  depended  merely  on  one 
cause ;  after  that  period,  strangulation  took  place — an  occurrence  which 
could  not  be  easily  diagnosed,  as  vomiting,  one  of  the  most  striking 
symptoms,  had  previously  existed. 

When  diarrhoea  occurs,  it  is  generally  at  the  commencement  of  the 
disease ;  and  it  is  remarkable  that  this  state  is  frequently  exchanged, 
rather  suddenly,  for  one  of  an  opposite  character.  Thus,  when  you 
have  succeeded  in  checking  the  diarrhoea  with  chalk  mixture  and  opium, 
a  state  of  costiveness  frequently  ensues ;  requiring  the  daily  use  of 
purgatives  and  enemata.  I  have  now  witnessed  several  cases  in  which 
the  moderate  use  of  opiates  and  astringents  brought  on  constipation, 
requiring  the  use  of  strong  purgatives,  and  enemata  thrown  up  with 
Eead^s  syringe. 

In  influenza,  as  in  many  other  febrile  affections,  the  lungs  become 
considerably  engaged;  the  disease  first  attacks  the  nose  and  throat, 
then  the  larynx  and  trachea,  and,  finally,  the  ultimate  ramifications  of 
the  bronchi.  There  are  several  other  affections  which  commence  in  a 
similar  way — as  ordinary  catarrh,  bronchitis,  and  measles.  In  influenza, 
most  persons  have  the  nose  and  throat  affected  in  the  beginning ;  the 
inflammation  creeps  gradually  along  the  lining  membrane  of  the  air- 
passages,  until  it  involves  the  greater  part,  or  the  whole,  of  the  bron- 
chial mucous  membrane.  The  progress  of  the  inflammation  is  ex- 
tremely rapid,  and  in  the  course  of  twenty-four,  or  even  twelve  hours, 
the  lungs  become  engaged. 

There  is,  however,  much  difference  as  to  the  extent  to  which  this  in- 
flammation proceeds.  In  many  cases,  it  is  limited  to  the  nose  and 
throat ;  the  patients  complain  of  coryza,  hoarseness,  and  slight  cough. 
In  others,  the  trachea  also  is  more  or  less  affected,  and  the  cough  is 
more  troublesome ;  but,  generally  speaking,  the  latter  as  well  as  the 
former  cases  are  unattended  with  fever.     The  patients  eat  and  drink  as 


INFLUENZA.  4-35 

usual,  go  about  their  ordinary  business,  and  sleep  tolerably  well  at 
night.  This  appears  to  be  the  general  course  of  the  disease  when  the 
inflammation  is  limited  to  the  nose,  throat,  and  upper  part  of  the  air- 
passages  ;  when  it  spreads  farther,  and  attacks  the  fiy^t  ramifications  of 
the  bronchi,  there  is  some  dyspnoea  and  tightness  of  chest,  the  cough 
is  much  more  troublesome,  and  the  appetite  and  digestion  are  some- 
what impaired ;  but  persons  in  this  state,  although  resting  badly  and 
eating  but  little,  will  continue  to  go  about — constantly,  however,  com- 
plaining that  they  are  very  ill.  When  the  smaller  divisions  and  ulti- 
mate ramifications  of  the  bronchi  are  engaged,  there  are  soreness  of  chest, 
remarkable  dyspnoea,  and  constant  harassing  cough ;  the  headache  is 
also  aggravated,  the  patient  looses  all  inclination  for  food,  sleeps  badly 
at  night,  and  is  confined  to  the  bed  or  house. 

First,  then,  you  have  the  mucous  membrane  of  the  eyes,  nose,  and 
throat  affected ;  then  the  larynx  and  trachea ;  then  the  larger  bronchi ; 
and,  finally,  the  smaller  and  more  minute  ramifications.  When  the 
latter  state  has  continued  for  some  time,  more  or  less  serous  engorge- 
ment of  the  lung  takes  place,  and  this  adds  to  to  the  dyspnoea  and 
cough.  On  applying  the  stethoscope  over  the  lungs,  you  will  hear  at 
various  parts  a  moist  crepitus,  indicating  the  existence  of  serous  infil- 
tration. The  smaller  bronchial  tubes  and  air- vesicles  are  congested  and 
fiUed  with  mucus  ;  the  blood  cannot  pass  freely  through  the  lung,  and 
consequently  must  be  imperfectly  aerated ;  the  secreting  and  absorbing 
functions  of  the  lung  are  deranged,  and  hence  arises  a  state  in  which 
the  pulmonary  capillaries  become  congested,  and  permit  the  more  fluid 
part  of  the  blood  to  exude  into  the  parenchyma  of  the  lung,  giving 
rise  to  what  is  termed  serous  infiltration. 

Something  similar  to  this  occurs  also  in  bronchitis,  particularly  in 
fever,  but  we  very  seldom  have  hepatisation  resulting  from  such  causes. 
In  hepatisation,  the  capillaries  pour  out,  not  serum,  but  lymph,  which 
glues  together  the  cells  of  the  pulmonary  tissue,  and  forms  a  dense 
solid  mass.  Hence,  in  influenza  or  bronchitis,  you  seldom  have  true 
pneumonic  inflammation.  You  wiU  have  extensive  and  dangerous  en- 
gorgement, but  when  you  examine  the  lung  after  death  you  do  not  find 
any  real  solidification,  and  you  can  restore  the  lung  almost  to  its  origi- 
nal permeability  and  4)uoyancy  by  squeezing  out  the  infiltrated  fluid. 
Yet  I  must  admit  that  this  is  not  always  the  case,  and  that  in  influenza, 
as  well  as  in  bronchitis,  you  may  have  true  pneumonia  superadded  to 
the  original  affection  of  the  lining  membrane.  This  occurred  in  the 
case  of  a  lady  whom  I  attended  in  Capel-street,  and  who  was  attacked 
with  influenza  shortly  before  delivery.  On  the  day  of  her  accouche- 
ment, pneumonia  was  superadded  to  the  bronchial  inflammation,  and 


436 


CLINICAL    MEDICINE. 


she  died  with  extensive  hepatisation  of  the  right  lung.  This  also  oc- 
curred in  the  case  of  a  man  of  middle  age,  residing  in  Suffolk-street, 
who  had  been  labouring  for  some  days  under  excessive  engorgement  of 
the  lung.  I  have  also  observed  the  same  occurrence  in  a  gentleman 
whom  I  attended  with  the  late  Mr.  CoUes,  in  Exchequer-street ;  and  in 
another  case  which  I  saw  in  Whitefriar- street. 

One  of  the  most  singular  features  in  the  history  of  influenza,  is  the 
extraordinary  degree  of  dyspnoea  witnessed  in  most  cases  where  the  lung 
is  extensively  engaged,  but  particularly  where  the  patients  had  been 
previously  subject  to  pulmonary  affections ;  and  even  in  many  cases 
where  the  bronchial  mucous  membrane  is  but  slightly  engaged,  the 
amount  of  dyspnoea  is  remarkably  great.  Indeed,  it  might  be  said  with 
mugh  truth,  that  the  dyspnoea  was  by  no  means  proportioned  to  the 
extent  of  pulmonary  inflammation.  There  was  a  case  in  the  hospital  of  a 
woman  labouring  under  influenza,  whose  chest  sounded  clear  on  percus- 
sion, and  in  whom  every  part  of  the  lung  was  permeable,  who  presented 
nothing  more  than  a  few  sonorous  rales  in  the  course  of  the  larger 
bronchial  tubes,  and  yet  she  was  suffering  from  considerable  dyspnoea, 
and  the  respirations  amounted  to  forty-six  in  a  minute.  We  cannot, 
therefore,  attribute  the  difficulty  of  breathing  to  mere  bronchitic  lesion, 
for  it  was  not  in  proportion  to  this  lesion.  Another  patient  admitted 
into  Sir  P.  Dun's  Hospital  exhibited  a  similar  train  of  symptoms.  He 
was  a  negro  sailor,  a  native  of  New  Brunswick,  and  was  seized  with  the 
epidemic  a  few  days  after  his  ship  arrived  in  Dublin ;  he  was  a  man  of 
Herculean  form  and  finely  developed  chest,  and  in  the  prime  of  life. 
His  suffering  from  dyspnoea  was  intense ;  his  chest  heaved,  he  tossed 
about  in  bed  in  a  constant  state  of  agitation  and  restlessness,  and  yet 
the  respiratory  murmur  was  every  where  distinctly  audible  through  the 
lung,  and  no  rale  could  be  heard,  except  here  and  there  a  few  bronchitic 
wheezings.  He  also  laboured  under  insomnia,  and,  though  he  had  but 
little  fever,  debility  was  extreme.  Indeed,  his  pulse  was  so  weak  from 
the  commencement,  that  I  could  not  venture  to  treat  him  antiphlogis- 
tically ;  and  I  accordingly  ordered  extensive  vesication  over  the  chest, 
with  the  use  of  wine,  stimulants,  and  narcotics.  This  man  subse- 
quently recovered — an  event  which  could  scarcely  have  occurred  under 
the  plan  of  treatment  adopted,  had  his  dyspnoea  depended  on  mere 
bronchitis. 

It  should  be  also  borne  in  mind,  that  in  many  bad  cases  of  influenza 
the  dyspnoea  is  intermittent,  or  at  least  undergoes  remarkable  exacerba- 
tions and  remissions  at  certain  hours  of  the  day  and  night.  It  would 
appear  that  the  respiratory  derangement  depends  on  the  same  general 
cause  which  produces  the  whole  train  of  symptoms,  and  that  it  might 


INFLUENZA.  437 

exist  even  where  there  was  no  bronchial  inflammation  at  all.  It  is  true, 
that  where  the  bronchitis  is  present,  it  adds  to  the  distress  of  respira- 
tion, but  the  dyspnoea  appears  to  be  chiefly  attributable  to  some  im- 
pression made  on  the  vital  activity  of  the  lung.  That  the  lungs  are 
endowed  with  an  inherent  vitality  necessary  to  the  aeration  of  the  blood, 
has  been  long  acknowledged  by  the  Germans,  who  have  described  a 
dyspnoea  from  paralysis  of  the  lungs ;  and  this  opinion  is  now  gene- 
rally adopted  in  Great  Britain,  since  the  results  of  the  experiments  on 
the  eighth  pair  of  nerves  have  been  duly  appreciated.  We  have  abun- 
dant illustrations  of  this  truth  in  asthma,  in  which  the  greatest  dyspnoea 
is  often  present,  without  any  appreciable  lesion  of  the  lung,  And  it 
would  be  a  fortunate  circumstance  for  the  patients  in  influenza,  if  this 
were  not  the  case ;  for  we  could  then  treat  the  affection  of  the  lung  as 
ordinary  bronchitis,  and  should  expect  to  find  it  amenable  to  the  ordi- 
nary remedies. 

You  are  aware  that  the  mortality  in  cases  of  ordinary  broncliitis  is 
extremely  small,  if  we  except  very  young  children  and  persons  advanced 
in  life.  In  adults,  when  met  by  prompt  and  appropriate  treatment,  it 
is  generally  a  very  manageable  disease,  and  seldom  proves  fatal,  unless 
combined  with  other  unfavourable  conditions.  This,  however,  is  not 
the  case  in  influenza,  nor  is  the  pulmonary  affection  so  easily  treated, 
or  the  dyspnoea  so  readily  controlled.  I  saw,  some  time  ago,  a  fine 
young  woman,  servant  to  a  gentleman  in  ritzwiUiam-street,  for  whom 
every  thing  had  been  done  which  the  best  and  most  skiKul  practice 
could  devise ;  but  her  condition,  when  I  saw  her  was  desperate,  and  she 
died  the  following  day :  yet  her  chest  sounded  well  on  percussion,  and 
we  could  hear  nothing  over  the  whole  lung,  except  a  few  sonorous  and 
sibilous  rales,  and  the  respiratory  murmur  seemed  every  where  nearly  as 
loud  as  natural.  Of  course,  such  a  lesion  of  the  nervous  influence  could 
not  last  long,  without  necessarily  inducing  pulmonary  congestion — an 
inevitable  consequence  of  imperfect  aeration  of  the  blood.  When  the 
eighth  pair  of  nerves  is  divided,  the  animal  is  slowly  suffocated ;  and,  on 
dissection,  the  lungs  are  found  engorged,  and  the  bronchial  mucous 
membrane  congested  and  inflamed.  May  not  the  affection  of  these 
parts  in  influenza  be  sometimes  induced  by  lesions  of  nervous  power  in 
the  lungs  ? 

To  the  late  Dr.  George  Greene,  Professor  of  the  Practice  of  Physic  to 
the  College  of  Physicians,  I  am  indebted  for  the  following  results  of  his 
very  numerous  post  mortem  examinations  in  this  disease,  and  I  feel 
great  pleasure  in  being  able  to  give  them,  as  such  examinations — at 
least  in  this  country,  are  very  rare  : — 

^'  The  cases  which  proved  fatal  at  the  House  of  Industry,  during  the 


438  CLINICAL   MEDICINE. 

late  epidemic  influenza  (1837),  occurred  principally  among  the  aged 
inmates  of  both  sexes.  I  had  an  opportunity  of  examining  several  of 
these  cases,  and  the  following  were  the  principal  post  mortem  appear- 
ances observed. 

"  The  bronchial  mucous  membrane  was  found,  in  every  case,  more 
or  less  congested  and  inflamed.  The  colour  varied  considerably — being 
in  some  of  a  dull  red,  and  in  others  of  a  much  darker  hue.  The  inflam- 
mation, in  most  cases,  was  found  to  occupy  both  the  trachea  and  the 
bronchial  tubes  of  both  lungs ;  in  other  instances,  it  was  confined  to 
one  lung  alone.  A  sanguinolent  frothy  mucus  occupied  the  area  of  the 
tubes,  and  increased  in  quantity  as  they  were  traced  to  their  minuter  divi- 
sions. The  parenchymatous  tissue  of  the  lung  was  invariably  discoloured, 
being  generally  of  a  dark  or  violet  colour ;  its  specific  gravity  was  in- 
creased, and  it  did  not  crepitate,  or  at  least  very  feebly,  when  pressed 
between  the  fingers.  The  surface  of  its  section  was  not  rough  to  the 
touch,  and  when  pressed  in  the  hand,  a  quantity  of  the  mucus  de- 
scribed above  was  driven  out.  In  some  cases,  the  postero-inferior  por- 
tions of  one  or  both  lungs  were  very  dark  coloured,  and  the  finger  could 
be  passed  easily  through  the  substance.  When  the  surface  thus  torn 
was  examined,  it  did  not  appear  to  be  granular ;  it  resembled  more  a 
portion  of  gangrenous  lung,  except  that  there  was  an  absence  of  fetor. 
This  last  appearance  was  found  principally  in  very  aged  persons.  It 
was  rare  to  find  any  traces  of  the  second  and  third  stages  of  ordinary 
pneumonia  in  these  patients ;  but  in  the  young  and  robust,  who  were 
received  into  the  Hardwicke  Fever  Hospital  from  the  neighbouring 
streets,  these  degenerations  of  the  structure  of  the  lung  were  observed, 
together  with  the  same  inflammation  of  the  bronchial  mucous  mem- 
brane. 

"  In  most  of  the  aged  patients,  the  blood  was  found  dark  coloured 
and  fluid  in  both  cavities  of  the  heart,  and  in  every  vessel  where  it  was 
examined.  The  cases  in  which  fibrinous  concretions  in  the  cavities  of 
the  heart  were  found,  were  very  few,  and  these  invariably  in  the  young 
or  middle  aged.  In  the  former  class  of  patients,  also,  the  lung  occa- 
sionally appeared  to  be  cedematous ;  and  in  one  or  two  cases,  a  con- 
siderable effusion  of  serum  had  taken  place  into  the  pleural  cavities. 
The  signs  of  recent  pleuritis  were  very  rare,  but  old  adhesions,  as  might 
be  expected  in  such  subjects,  were  very  commonly  found  between  the 
pulmonary  and  costal  pleurse.  In  one  case  of  a  lunatic,  who  survived 
the  immediate  attack  of  influenza,  tubercles  appeared  to  have  been 
rapidly  developed  in  both  lungs.  In  another  lunatic,  two  tubercular 
cavities  were  found  in  addition  to  the  state  of  the  lung  and  air-tubes 
already  adverted  to. 


INFLUENZA.  439 

"  With  respect  to  the  nature  and  duration  of  the  symptoms  of  those 
cases  which  came  under  my  own  management,  I  have  httle  to  say  in 
addition  to  what  is  already  so  familiarly  known.  The  physical  signs 
afforded  by  percussion  and  auscultation  were  almost  universally  as 
follows : — Dulness,  more  or  less  decidedly  marked,  in  the  postero-in- 
ferior  portions  of  the  lungs ;  sonorous  or  some  form  of  bronchial  rale 
throughout  the  chest,  or,  what  was  more  common,  a  mixed  sonorous 
and  crepitating  rale,  or  in  the  latter  stages,  a  muco-crepitating  rale.  The 
sputa  were  seldom  rust-coloured  or  tenacious,  but  rather  resembled 
those  of  bronchitis.  In  many  cases,  the  want  of  power  to  excrete  them 
appeared  to  be  the  immediate  cause  of  death ;  but  in  others,  the  morbid 
cause,  whatever  it  might  be,  appeared  to  have  affected  the  entire  respi- 
ratory and  circulating  systems,  producing  great  congestion  of  the  venous 
system,  and  a  state  not  unlike  asphyxia.  The  latter  cases  were  almost 
all  among  the  aged  inmates  of  the  House  of  Industry. 

"The  appearances  of  the  other  viscera  were  not  such  as  could 
in  any  way  account  for  the  result,  so  often  speedily  fatal;  so  that 
so  far  as  one  could  hazard  a  conjecture,  the  morbid  cause  appeared 
to  have  made  its  primary  impression  on  the  respiratory  mucous  sur- 
face, thereby  interfering  with  the  proper  aeration  of  the  blood,  and  in- 
ducing the  changes  in  that  fluid  and  in  the  structure  of  the  lungs  above 
detailed.'' 

Such  were  the  appearances  observed  by  Dr.  Greene  in  numerous  dis- 
sections of  persons  who  died  of  influenza.  They  may  be  rehed  on  as 
perfectly  accurate,  for  no  one  was  better  acquainted  with  pathological 
phenomena  than  Dr.  Greene,  and  consequently  no  one  better  able  to 
furnish  valuable  evidence  with  respect  to  the  appreciable  changes  pro- 
duced by  influenza  in  the  pulmonary  and  other  tissues. 

I  have  abeady  advanced  the  opinion,  that  we  should  not  hastily 
assume  that  influenza  consists  essentially  in  the  morbid  changes  which 
dissection  reveals ;  we  should  examine  every  side  of  the  question,  and 
consider  whether  it  is  not  possible  that  the  alterations  in  the  pulmonary 
tissue  may  not  be,  to  some  extent  at  least,  the  consequences  of  the 
disease.  Let  us  consider  for  a  moment  the  method  we  pursue  in  rea- 
soning about  the  progress  and  causes  of  the  symptoms  in  ordinary 
bronchitis.  Here  a  patient  is  seized  with  a  pectoral  affection,  attended 
with  cough,  dyspnoea,  and  more  or  less  fever.  We  find  certain  rales,  and 
the  expectoration  is  altered  in  quality  and  quantity.  Further,  observing  a 
number  of  such  cases,  we  remark  that  the  danger  is  proportioned  to 
the  degree  of  dyspnoea,  and  the  dyspnoea  to  the  extent  and  nature  of 
the  rales,  together  with  the  quantity  and  quality  of  the  expectoration. 
To  these  the  general  constitutional  affection,  and  the  probable  results 


440  CLINICAL   MEDICINE. 

of  the  disease,  have  certain  definite  relations,  a  knowledge  of  which  is 
soon  obtained  by  experience. 

But  these  rales,  and  this  state  of  the  respiration  and  expectoration, 
we  have  reason  to  believe,  arise  from  the  presence  of  bronchial  inflam- 
mation ;  and  to  this  we  refer  all  the  symptoms  observed.  On  this  sup- 
position, too,  we  proceed  in  our  treatment,  and  the  result  most  com- 
monly justifies  its  correctness ;  and  we  have  additional  evidence  of  its 
truth  furnished  by  post-mortem  examinations.  Now,  in  such  instances, 
the  chain  of  inductive  evidence  is  complete,  and  we  feel  a  conviction 
that  our  practice  is  founded  on  correct  notions  of  the  nature  of  the 
disease.  But  how  different  is  the  case  when  we  assume  that  influenza 
is  caused  by  bronchial  inflammation  !  In  influenza  the  dyspnoea  is  not 
always  proportioned  to  the  bronchitic  affection — nay,  in  some  cases  we 
have  seen  that  difficulty  of  breathing  was  most  urgent  in  cases  where 
the  air  entered  into  all  parts  of  the  lung  with  facihty,  and  where  few 
and  unimportant  rales  existed.  Again,  although  the  presence  of  a 
copious  viscid  secretion  in  the  bronchial  tubes  was  sure  to  aggravate 
dyspnoea,  yet  it  often  occurred  in  patients  whose  air-passages  were  very 
little,  or  not  at  all,  obstructed  in  this  way.  The  effects,  too,  of  reme- 
dies, antiphlogistic,  expectorant,  and  derivative,  were  very  different  from 
what  they  would  have  been  had  the  disease  depended  on  a  mere  bron- 
chitis. I  have  already  stated  my  conviction,  that  the  poison  which 
produced  influenza  acted  on  the  nervous  system  in  general,  and  on  the 
pulmonary  nerves  in  particular,  in  such  a  way  as  to  produce  symptoms 
of  bronchial  irritation  and  dyspnoea  to  which  bronchial  congestion  and 
inflammation  were  often  superadded. 

In  this  view  of  the  subject  I  am  not  singular,  for  I  find  that  it  has 
been  advocated  by  Dr.  Peyton  Blakiston,  in  a  short  treatise  on  influenza, 
as  it  occurred  at  Birmingham.  He  states  that  his  researches  have  led 
him  to  the  conclusion,  "  that  influenza  is  an  affection  of  the  nervous 
system,  with  its  concomitant  derangements  in  the  organs  of  digestion, 
circulation,  &c.,  commonly  known  under  the  name  of  nervous  fever, 
accompanied  throughout  its  whole  course  by  irritation  of  the  pulmonary 
mucous  membrane,  which  not  unfrequently  amounts  to  congestion,  and 
even  to  inflammation.''^ 

This  distinction  between  influenza  and  feverish  cold  with  bron- 
chitis is,  in  a  practical  point  of  view,  of  great  importance,  and 
should  never  be  lost  sight  of  in  the  treatment  of  influenza,  for  it 
prevents  us  from  placing  our  sole  confidence  in  remedies  adapted 
to  mere  bronchitic  inflammation.  Thus,  Dr.  Blakiston  asserts,  and 
most  physicians  will  agree  with  him  in  this  point  at  least,  that  it  was 
often  necessary  to  have  recourse  to  diffusible  stimulants  at  the  com- 


INFLUENZA.  441 

mencement,  and  to  administer  tonic  medicines  in  an  early  stage  of  the 
disease. 

In  some  cases,  even  when  dyspnoea  exists,  the  cough  is  hard  and  dry, 
and  the  expectoration  scanty ;  in  others,  the  expectoration  is  copious, 
so  as  to  cause  constant  efforts  to  cough  it  up ;  and,  indeed,  it  is  melan- 
choly to  look  at  the  distress  which  patients  suffer  in  this  respect.  You 
will  hear  the  wheezing  of  the  phlegm  in  the  throat  and  air-passages  be- 
fore you  enter  the  room,  and  you  will  see  the  patient  exhausted  by 
successive  paroxysms  of  cough,  and  ineffectual  attempts  to  expectorate. 
In  other  cases,  where  the  vitality  of  the  lung  is  less  injured,  and  the 
general  tone  of  the  system  less  deranged,  the  sputa,  although  copious, 
are  expectorated  with  considerable  facility. 

The  sputa  bear  considerable  analogy  to  those  observed  in  ordinary 
bronchitis.  They  consist  at  first  of  a  greyish  mucus ;  as  the  disease 
proceeds  they  exhibit  a  globular  appearance,  or  assume  a  puriform  cha- 
racter, and  do  not  coalesce.  In  other  cases  they  are  extremely  viscid 
and  ropy,  like  solutions  of  gum  or  isinglass.  A  remarkable  fact  with 
respect  to  the  sputa  in  influenza  is,  that  they  are  very  seldom  mixed 
with  air-bubbles.  On  mentioning  this  to  some  persons  attending  my 
class,  I  was  shown  some  sputa  discharged  by  a  patient  labouring  under 
influenza,  in  which  there  were  some  air-bubbles ;  this,  however,  is  ex- 
tremely rare.  In  a  lecture  wliich  I  delivered  some  time  ago,  I  took 
occasion  to  allude  to  the  secretions  of  the  bronchial  mucous  membrane, 
and  stated  my  conviction  that  this  subject  had  not  received  as  yet  the 
attention  which  its  acknowledged  importance  demands.  There  is  one 
point,  in  particular,  of  which  no  adequate  explanation  has  been  as  yet 
given — namely,  why  it  is  that  in  some  cases  of  pulmonary  inflammation 
the  sputa  are  filled  with  air-bubbles,  while  in  other  instances  there  is 
no  appearance  of  air-bubbles  from  the  beginning  to  the  end  of  the 
disease. 

The  presence  of  air-bubbles  in  the  sputa  has  been  explained,  by 
supposing  that  air  becomes  incorporated  with  the  mucus  while  it  is 
driven  up  and  down  in  the  bronchial  tubes  during  the  acts  of  respira- 
tion and  coughing;  just  as  if  you  shake  a  solution  of  soap  or  any  other 
viscid  fluid  in  a  half-empty  bottle,  it  becomes  impregnated  with  air- 
bubbles.  There  may  be  some  truth  in  this,  but  I  think  it  does  not 
sufficiently  explain  the  presence  and  intimate  incorporation  of  air  with 
the  sputa  in  certain  affections  of  the  lung ;  and  it  appears  to  me  that 
we  can  scarcely  understand  this,  unless  we  suppose  that  the  air  and 
mucus  are  secreted  together.  You  are  aware  that  air  is  secreted  by 
the  bronchial  mucous  membrane,  and  that  in  come  cases  this  secretion 
is  morbidly  increased,  in  others  morbidly  diminished.     Now,  it  is  not 


442  CLINICAL  MEDICINE. 

very  unreasonable  to  suppose  that  the  mucous  membrane  may  secrete 
air  and  mucus  together  in  abnormal  quantity;  and  that  this,  rather 
than  any  mechanical  agitation,  may  be  the  cause  of  the  intimate  com- 
bination of  air  with  the  expectorated  fluids. 

I  need  scarcely  make  any  observation  on  the  cough  in  influenza.  It 
is  in  general  very  troublesome,  particularly  at  night.  Many  persons 
are  not  much  annoyed  by  it  during  the  day,  but  at  night  it  becomes 
very  harassing,  and  prevents  them  from  sleeping.  When  severe,  it 
continues  both  night  and  day ;  and  even  when  persons  have  recovered 
from  the  fever  and  dyspnoea,  and  are  able  to  go  about,  the  cough  will 
continue  extremely  troublesome :  this  I  have  observed  in  the  majority 
of  cases.  In  this  state  medicines  prove  of  very  little  service,  and  one 
of  the  best  remedies  is  to  change  to  a  mild  country  air.  Cases  of  cough, 
in  which  I  had  tried  every  remedy  without  success,  and  which  had  re- 
sisted every  form  of  treatment  in  the  city,  yielded  in  a  few  days  to  the 
salubrious  influence  of  change  of  air. 

In  influenza,  the  urine  is  generally  much  loaded  with  lithates,  and 
contains  a  lage  quantity  of  uro-erethrine  or  purpurine.  It  is  red  when 
voided,  deposits  a  good  deal  of  sediment,  and  tinges  the  vessel  in 
which  it  lies  with  a  pink  film.  It  bears  some  resemblance  to  the  urine 
which  accompanies  arthritic  and  gouty  affections.  In  very  bad  cases, 
this  state  of  the  urine  continues  up  to  the  period  of  death.  You  recol- 
lect what  I  stated  with  regard  to  the  condition  of  the  blood ;  it  is 
generally  buffed,  even  where  there  is  scarcely  any  febrile  excitement  in 
the  system,  and  thus  affords  a  very  fallacious  indication.  The  same 
observation  holds  good  with  respect  to  the  state  of  the  urine  and  tem- 
perature of  the  skin.  I  may  observe  here,  that  the  heat  of  skin  is 
very  variable ;  it  is  sometimes  very  high,  sometimes  natural :  in  fact, 
like  the  pulse,  it  falls  and  rises  in  a  very  remarkable  manner,  at  certain 
times  in  the  day. 

I  have  already  spoken  of  the  affection  of  the  mucous  membrane  of 
the  bowels.  I  may  observe,  that  in  some  cases  of  influenza  the  morbid 
influence  is  translated  to  the  brain,  and  symptoms  of  delirium  or  coma 
supervene.  Thus,  in  two  instances  that  have  been  communicated  to  me, 
the  patients  fell  into  a  state  resembling  coma,  during  the  course  of  the 
disease.  In  three  cases  witnessed  by  the  late  Mr.  Swift,  the  attack  of 
influenza  terminated  in  a  train  of  symptoms  bearing  a  close  analogy  to 
delirium  tremens,  and  requiring  the  use  of  blisters  to  the  head  and  nape 
of  the  neck,  full  doses  of  opium,  purgative  enemata,  wine,  and  the  occa- 
sional use  of  mercurials.  The  patients  complained  of  great  headache, 
noise  in  the  ears,  intolerance  of  light,  and  more  or  less  sleeplessness  from 
the  commencement,  along  with  the  usual  pulmonary  symptoms.     After 


INFLUENZA.  44,3 

five  or  six  days,  they  became  excessively  nervous,  lost  all  sleep,  had  con- 
tinued subsultus  and  tremors,  and  talked  very  incoherently,  particularly 
at  night.  During  the  prevalence  of  the  cerebral  symptoms,  the  pulmonary 
affection  partially  or  wholly  disappeared,  but  returned  again  in  some 
degree  after  the  subsidence  of  the  delirium.  All  these  cases  terminated 
favourably. 

I  believe  I  have  already  remarked,  that  many  persons  vrho  have  laboured 
under  very  severe  pulmonary  symptoms  will  struggle  through  the  disease; 
and  I  may  mention  here  that  I  have  seen  persons  recover,  who  have  suf- 
fered from  continued  orthopnoea  for  three  weeks.  Still  the  mortality, 
particularly  among  the  aged,  is  very  great ;  and  I  fear  that  we  shall 
shortly  have  but  few  octogenarians  to  tell  the  occurrences  of  the  last  cen- 
tury. Indeed,  the  mortality  has  not  been  confined  exclusively  to  the 
aged,  for  many  persons  in  the  vigour  of  life  have  sunk  under  the  attack. 
There  have  been  several  deaths  among  the  soldiers  in  our  garrisons,  not- 
withstanding the  excellent  state  of  health  which  our  troops  generally  enjoy, 
and  the  skilful  and  judicious  treatment  of  our  present  army  surgeons. 

In  many  individuals  influenza  has  laid  the  foundation  of  other  and 
very  serious  diseases,  and  this  I  especially  witnessed  in  the  epidemic 
of  1847.  In  some,  the  diseases  so  produced  could  be  traced  to  the 
depressing  efi^ect  on  the  nervous  system.  Thus,  Dr.  Mulock  informs  me 
that  in  three  cases  which  he  attended,  relapse  from  exposure  to  cold 
terminated  in  insanity,  which  in  one  of  the  cases  ended  fatally. 

It  now  remains  for  me  to  say  a  few  words  concerning  treatment.  First, 
as  to  bleeding.  A  great  deal  was  expected  from  general  bleeding,  because 
the  disease  was  sudden  and  violent  in  its  onset,  and  accompanied  by 
symptoms  which  seemed  to  require  active  measures — such  as  an  inflam- 
matory state  of  the  bronchial  mucous  membrane,  accompanied  by  quick 
pulse,  hot  skin,  and  high-coloured  urine.  This  led  persons  to  expect 
much  benefit  from  venesection.  The  results,  however,  of  its  employment 
are,  generally  speaking,  unsatisfactory.  Where  venesection  was  employed 
promptly  and  in  the  beginning  of  the  disease,  and  where  it  seemed  to  be 
strongly  indicated  by  the  buffed  and  cupped  state  of  the  blood,  even  in 
such  cases  it  has  failed  to  afford  any  thing  like  material  or  permanent 
benefit,  or  to  produce  a  decided  amelioration  of  the  existing  symptoms. 
The  general  impression  among  practitioners  in  Dublin  seems  to  be,  that 
bleeding  is  doubtful  in  its  effects,  if  not  altogether  improper.  I  am  much 
inclined  to  think  that  bleeding,  unless  employed  within  the  first  twelve 
or  twenty -four  hours,  will  be  likely  to  do  as  much  or  more  harm  than 
good.  Bleeding  on  the  second  or  third  day,  except  to  relieve  congestion 
of  the  lungs,  seems  inadmissible.  The  same  observation  holds  good 
with  reference  to  other  diseases.     Thus,  in  scarlatina,  if  you  happen  to 


444  CLINICAL  MEDICINE. 

be  called  when  the  rigor  commences,  and  while  the  disease  is  beginning 
to  form,  you  will  sometimes  accomplish  much  good  by  bleeding  your 
patient ;  but  after  eighteen  or  twenty-four  hours,  when  the  disease  is 
fully  formed,  venesection  will  not  do.  On  this  point  I  can  speak  from 
experience.  In  scarlatina,  the  difference  of  a  few  hours  renders  venesec- 
tion inapplicable,  and  even  injurious.  It  is  the  same  thing  with  respect 
to  influenza ;  general  bleeding  is  useful  only  in  the  commencement,  and 
where  the  symptoms  seem  to  demand  it,  it  should  be  employed  at  least 
within  the  first  twenty-four  hours. 

Where  I  have  been  fortunate  enough  to  find  the  disease  just  com- 
mencing, I  bleed  to  the  amount  of  twelve  or  fourteen  ounces,  order  the 
patient  to  remain  in  bed  and  take  some  aperient,  followed  by  the  use  of 
nitre.  In  this  way,  by  timely  bleeding,  aperients,  sudorifics,  and  con- 
finement to  bed,  the  attack  generally  passes  over  in  two  or  three  days. 
I  could  mention  many  instances  of  the  success  of  this  plan  of  treatment. 
In  one  family  I  treated  all  the  individuals  attacked  in  this  way,  and  I 
have  done  the  same  thing  in  many  cases  of  persons  somewhat  advanced 
in  Hfe.  In  the  case  of  an  old  gentleman,  who  was  very  severely  at- 
tacked, I  succeeded  by  these  means  in  checking  the  disease  at  once. 
My  experience,  therefore,  is,  that  bleeding  is  of  service  in  the  very  com- 
mencement of  the  disease ;  but  as  it  seldom  happens  that  a  physician  is 
called  in  at  this  period,  I  would  qualify  my  statement  by  saying,  that, 
as  a  general  measure,  bleeding  in  influenza  is  seldom  admissible. 

When  you  are  called  on  to  attend  cases,  you  will  most  generally  find 
that  the  patients  have  been  ill  for  two  or  three  days  or  more ;  and  then 
the  only  mode  of  abstracting  blood,  which  you  can  have  recourse  to  with 
safety,  is  by  leeching.  About  eight  or  ten  leeches  applied  over  the  hol- 
low of  the  neck,  just  above  the  sternum,  and  allowed  to  bleed  pretty 
freely,  will  prove  very  serviceable  ;  and  if  you  apply  them  in  the 
evening,  you  will  often  secure  to  your  patient  a  good  night's  rest.  This 
plan  of  leeching  the  hollow  of  the  neck,  in  cases  of  tracheo-bronchial 
inflammation,  is  an  excellent  one  :  the  leeches  are  applied  at  a  spot 
which  lies  close  to  the  trachea,  and  particularly  to  that  point  to  which 
the  irritation  accompanying  bronchitic  affections  is  chiefly  referred. 

By  the  aid  of  leeching,  the  use  of  aperients — if  necessary,  and  confine- 
ment to  bed,  with  sudorifics,  you  will  frequently  succeed  in  removing 
the  fever  and  bronchial  inflammation.  You  will  derive  much  benefit, 
particularly  in  the  early  stage  of  influenza,  from  tartar  emetic  and 
nitre ;  but  I  must  say,  that  neither  leeching  nor  tartar  emetic  and  nitre 
proves  as  valuable  and  as  efficacious,  in  influenza,  as  in  ordinary  bron- 
chitis. Some  of  my  friends,  who  use  tartar  emetic  as  a  nauseant  in 
the  commencement  of  the  disease,  inform  me  that  they  have  derived 


INFLUENZA.  ,  445 

benefit  from  its  use ;  and  others  have  told  me  that  they  have  used  tartar 
emetic  and  opium  in  the  commencement  and  during  the  course  of  the 
disease,  with  advantage.  I  have  not  employed  the  first  of  these,  but  I 
have  the  latter,  and  with  favourable  results.  You  may,  therefore,  after 
using  antiphlogistics  for  a  day  or  two,  proceed  to  the  use  of  opiates,  in 
combination  with  tartar  emetic  or  nitre.  In  some  cases,  the  campho- 
rated tincture  of  opium  will  answer  very  well ;  in  others,  you  will  find 
the  acetate  or  muriate  of  morphia  better.  A  mixture,  composed  of  six 
ounces  of  almond  emulsion,  a  drachm  of  nitre,  and  half  a  drachm  or 
more  of  the  liquor  muriatis  morphise,  will  be  found  very  useful.  The 
muriate  of  morphia,  which  possesses  many  of  the  valuable  properties  of 
opium  without  its  defects,  will  serve  to  tranquillize  the  system  and  pro- 
duce sleep — two  most  important  points  in  a  disease  like  influenza  con- 
nected with  increased  nervous  irritability. 

A  gentleman  on  whom  I  place  much  reliance,  tells  me  that  he  has 
treated  many  bad  cases  successfully  with  camphor  mixture,  tincture  of 
opium,  and  tartar  emetic.  I  need  not  mention  the  various  remedies 
which  have  been  recommended  in  this  disease — as  Mindererus'  spirit, 
Hoffman's  anodyne,  ipecacuanha — alone  or  combined  with  extract  of 
conium  and  blue  pill,  and  many  other  remedies  belonging  to  the  class 
of  diaphoretics  or  expectorants.  They  are  all  more  or  less  serviceable, 
but  they  have  all  the  common  defect  of  producing  less  relief  than  they 
usually  do  in  cases  where  the  pulmonary  affection  is  simple  and  idio- 
pathic. Towards  the  end  of  the  disease,  you  find  it  necessary  to  give 
stimulating  expectorants  and  light  tonics — as  infusion  of  poly  gala  senega, 
infusion  of  columba,  &c. 

One  word  about  blisters,  before  I  conclude.  They  are  useful  in  some 
cases,  but  in  many  of  the  severe  ones  they  do  little  or  no  good,  and  only 
add  to  the  patient's  sufferings.  They  do  not  reheve  the  pulmonary 
symptoms,  and  particularly  the  dyspnoea,  in  the  manner  you  would  be 
prepared  to  expect.  I  do  not  know  a  more  remarkable  circumstance, 
in  the  present  disease,  than  the  failure  of  blisters ;  and  in  many  cases  I 
do  not  employ  them  at  all.  Fomenting  the  trachea  and  chest  with  very 
hot  water  appears  to  be  much  more  serviceable.  This  has  proved  ex- 
tremely valuable  in  many  cases  of  this  as  well  as  other  affections  of  the 
air  passages. 


446 


LECTURE  XXX. 


THE    CONNEXION   BETWEEN   DISEASES   OF   DIFFERENT   ORGANS. 

In  order  to  acquire  a  correct  and  available  knowledge  of  human  patho- 
logy, and  to  extend  the  range  and  confirm  the  accuracy  of  diagnosis,  it 
is  of  the  utmost  importance  to  observe  attentively  the  connexion  between 
the  diseases  of  certain  organs  or  systems  of  the  body.  You  are  aware 
that  some  organs,  when  labouring  under  disease,  are  apt,  after  the  dis- 
ease has  continued  some  time,  to  implicate  other  organs,  giving  rise  to 
various  deranged  conditions,  which  are  developed,  sometimes  simulta- 
neously, but  in  general  consecutively,  and  in  sequence.  I  have  already 
pointed  out  several  diseased  actions  thus  associated  together,  each  forming 
a  link  in  the  morbid  chain.  Now  it  is  of  the  greatest  importance  to  study 
each  link,  and  ascertain  the  nature  of  its  connexion,  so  as  to  have  a  dis- 
tinct conception  of  the  whole. 

Let  me  first  direct  your  attention  to  a  train  of  morbid  phenomena 
sometimes  observed  co-existing  with  arthritic  inflammation.  A  person 
labouring  under  inflammation  of  the  joints  gets  an  attack  of  hepatitis, 
accompanied  by  jaundice,  and  this  is  followed  by  urticaria.  I  have 
observed  this  sequence  of  disease  in  eight  or  nine  cases.  The  first  was 
in  a  gentleman  residing  in  Lower  Mount-street,  whom  I  attended  with 
Dr.  Cheyne.  This  gentleman,  in  consequence  of  exposure  to  cold,  was 
attacked  with  arthritic  inflammation  and  fever.  After  he  had  been  about 
ten  days  ill,  he  became  suddenly  jaundiced,  and  in  a  day  or  two  after- 
wards a  copious  eruption  of  urticaria  appeared  over  his  body  and  limbs. 
Exactly  the  same  train  of  phenomena,  and  in  a  similar  order  of  succession, 
was  observed  in  a  man  treated  in  the  Meath  Hospital  in  1832.  A  short 
time  before  this,  I  had  been  attending  a  medical  friend  in  Baggot-street, 
who  had  been  affected  in  the  same  way ;  and  I  mentioned  to  the  class, 
as  soon  as  I  perceived  the  man  was  jaundiced,  that  he  would  most  pro- 
bably get  urticaria.  I  made  a  similar  prediction  in  a  case  which  occurred 
recently  in  our  wards,  and  it  was  verified  by  the  event.     Now  tliis  is  not 


THE  CONNEXION  BETWEEN  DISEASES  OF  DIFFERENT  ORGANS.         447 

a  mere  fortuitous  occurrence ;  the  various  symptoms  must  be  connected 
ill  the  relation  of  cause  and  effect.  It  is  interesting  to  bear  this  in  mind, 
and  it  is  besides  of  considerable  importance  to  the  practising  physician ; 
it  enables  him  to  predict  the  appearance  and  form  of  disease,  and  inspires 
his  patient  with  confidence  in  his  opinions  and  judgment. 

Since  my  attention  has  been  drawn  to  the  connexion  between  these 
three  diseases,  I  have  seen  and  heard  of  several  other  instances  in  which 
they  appeared  thus  associated  together.  A  circumstance  so  remarkable 
deserves  to  be  studied  with  more  than  ordinary  interest.  Let  us,  there- 
fore, consider  what  facts  are  supplied  by  physiology  and  pathology 
capable  of  throwing  some  light  upon  this  hitherto  unobserved  and  un- 
cultivated subject.  In  the  first  place,  nothing  has  been  longer  recog- 
nised by  physicians,  as  an  established  fact,  than  the  intimate  sympathy 
which  exists,  both  in  health  and  disease,  between  the  digestive  organs 
and  the  skin.  Now,  acute  hepatitis  always  produces  more  or  less  de- 
rangement of  the  stomach  and  alimentary  canal,  and  we  may  therefore 
consider  its  connexion  with  urticaria  in  the  same  way  that  we  are  in 
the  habit  of  viewing  the  cases,  so  frequently  observed,  in  which  certain 
sorts  of  fish  have  produced  serious  symptoms  of  indigestion  followed 
by  nettle  rash.  The  association  between  these  two  diseases  is  rendered 
more  remarkable  by  the  fact,  that,  when  fish  taken  as  food  exerts  a 
poisonous  effect  on  the  system,  it  frequently  produces  not  merely  violent 
stomach  and  bowel  complaint,  but  also  inflammation  of  the  joints  and 
rheumatic  pains.  If  I  can  establish  this,  you  will  allow  that  the  con- 
nexion between  arthritis,  disease  of  the  digestive  organs,  and  urticaria, 
can  no  longer  be  considered  as  fortuitous  and  depending  on  the  acci- 
dental concurrence  of  causes  having  no  determinate  relation,  but  must 
be  looked  on  as  owing  to  and  arising  from  the  operation  of  some  fixed 
law  which  regulates  and  originates  this  development  of  morbid  actions 
in,  if  not  a  frequent,  at  least  an  uniform  mode  of  succession. 

The  Otaheitan  eel  (puhhe  pirrre  rowte)  produces,  when  eaten,  a  most 
copious  scarlet  erruption  of  the  skin — most  probably  urticaria — and  oc- 
casions sudden  tumefaction  of  the  abdomen,  together  with  swelling  of  the 
extremities,  hands  and  feet ;  the  pain  felt  in  the  limbs  is  so  excruciating 
that  the  patient  becomes  quite  frantic.  I  may  remark  here  that  this  and 
many  other  species  of  fish  which  act  as  poisons  on  the  system,  give  rise 
very  speedily  to  paralysis  of  the  extremities.  You  wiU  find  in  the  Edin- 
burgh Medical  and  Surgical  Journal,  vol.  iv.  p.  396,  in  an  excellent 
review  of  Dr.  Chisholm's  work  on  the  poison  of  fish,  an  account  of  the 
effects  produced  by  eating  the  Murcena  conger,  the  following  passage  : 
"  In  the  course  of  the  following  night,  they  were  all  seized  with  violent 
griping  and  cholera,  together  with  a  peculiar  sensation  of  the  lower  ex- 


448  CLINICAL   MEDICINE. 

tremities,  attended  with  violent  convulsive  twitches,  and  faintings. 
They  all  perceived  a  brassy  taste  in  the  mouth,  and  a  rawness  of  the 
oesophagus  as  if  it  had  been  excoriated.  These  symptoms  continued  to 
afflict  the  negroes  for  a  fortnight,  and  then  terminated  in  paralysis  of 
the  lower  extremities.  After  suffering  for  several  months,  they  recovered 
with  difficulty." 

Werlhoff,  as  cited  by  my  friend  Dr.  Autenrieth  in  a  book"^  of  extra- 
ordinary ability  and  research,  gave  a  case  where  the  Gadus  (Eglesinus 
asellus  produced  a  violent  affection  of  the  stomach  and  bowels,  together 
with  urticaria.  Urticaria,  diarrhoea,  dysentery,  paraplegia,  are  said,  by 
the  same  author,  to  be  frequently  observed  in  consequence  of  eating 
the  flesh  of  the  gray  snapper.  Eorster  relates  a  similar  train  of  acci- 
dents produced  by  eating  the  Sparus  pargus  (porgee).  In  short,  I  could 
bring  forward  citation  after  citation  in  proof  of  the  truth  above  ad- 
vanced ;  but  I  have  done,  for  enough  has  been  already  said  to  establish 
the  point  in  question. 

Having  established  the  fact  that  disease  of  the  digestive  organs  is 
often  intimately  associated  with  urticaria,  it  remains  to  prove  that  a 
similar  connexion  exists  between  hepatitis — the  cause  of  the  derange- 
ment in  the  digestive  organs  (in  the  case  before  us),  and  arthritis. 
Every  one  has  observed  how  frequently  inflammation  of  the  joints  be- 
comes in  its  course  complicated  with  inflammatory  affections  of  internal 
viscera.  In  general,  those  viscera  whose  component  tissues  are  most 
similar  to  the  articular  are  the  organs  affected.  Hence  the  heart  and 
pericardium  are  so  often  attacked  in  the  course  of  rheumatic  fevers.  It 
sometimes  happens,  however,  although  less  frequently,  that  the  internal 
organ  attacked  has  little  analogy  in  point  of  tissue  with  the  joints. 
Thus,  in  rheumatism  and  in  gout,  the  stomach,  the  bowels,  the  lungs, 
or  the  liver,  may  become  engaged  ;  and  of  these  none,  perhaps,  so  fre- 
quently as  the  liver.  We  need  not  be  surprised  at  this,  when  we 
consider  how  intimately  the  digestive  function  is  connected  with  arthri- 
tic inflammation,  which  is  indeed  generally  preceded  or  accompanied  by 
weU-marked  symptoms  of  hepatic  and  stomach  complaints.  Indeed, 
almost  all  medicines  that  afford  relief  in  arthritis  are  attended  with  well- 
marked  symptoms  of  their  having  acted  upon  the  secretions  of  the 
alimentary  canal  and  liver.  Thus  colchicum  seldom  diminishes  the 
pain  and  inflammation  of  the  joints,  until  it  produces  copious  bilious 
evacuations. 

There  is  another  sequence  of  disease,  not  unfrequently  observed,  but 
of  which  the  connexion  has  not  been  hitherto  noticed  by  any  writer, 

*  Ueber  das  Gift  der  Fische.     Tubingen,  1833. 


k 


THE    CONNEXION    BETWEEN    DISEASES    OF    DIFFERENT    ORGANS.    449 

as  far  as  I  can  ascertain.  About  two  years  since,  I  was  consulted  by  an 
English  gentleman,  who  had  been  ill  for  a  considerable  time.  The  his- 
tory of  his  case  from  the  commencement  was  this  : — Three  years  pre- 
viously he  had  venereal, — used  and  abused  mercury,  was  exposed  to  cold, 
and  got  periostitis.  He  now  got  into  a  bad  state  of  health,  used  mercury 
a  second  time,  obtained  some  relief,  and  then  relapsed  again ;  finally, 
after  having  used  mercury  three  or  four  times,  he  was  attacked  with 
mercurial  cachexy,  became  weak  and  emaciated ;  the  periostitis  degene- 
rated into  ostitis,  producing  superficial  caries  and  nodes  of  a  bad  char- 
acter j  he  had  exfoliation  of  the  bones  of  the  cranium  and  rupia,  and  was 
reduced  to  a  most  miserable  state.  Under  my  care  the  symptoms  gra- 
dually disappeared ;  he  recovered  to  all  appearance,  and  even  got  fat. 
He  then  caught  cold  and  relapsed  again.  At  last  his  Hver  became 
engaged ;  he  was  attacked  with  hypertrophy  of  the  liver,  ascites,  and 
jaundice,  and  died  soon  afterwards. 

Here,  then,  we  have  venereal,  abuse  of  mercury,  periostitic  inflamma- 
tion :  abuse  of  mercury  followed  by  exacerbation  of  the  periostitis  and 
establishment  of  mercurial  cachexy ;  and  the  history  of  the  case  is  wound 
up  with  hypertrophy  of  the  liver.  This  was  the  first  case  in  which  I 
had  observed  this  concatenation  of  diseases ;  since  that  period  I  have 
seen  a  similar  train  of  morbid  phenomena,  twice  in  private  practice  and 
once  in  hospital.  First,  we  have  abuse  of  mercury,  then  periostitic  in- 
flammation and  mercurial  cachexy,  and  the  scene  is  closed  by  morbid 
enlargement  of  the  liver.  Now  I  do  not  look  upon  this  sequence  as 
merely  fortuitous.  The  diseased  actions  are,  I  think,  related  as  cause 
and  effect,  and  each  successive  condition  is  consequent  on  the  previous 
one. 

It  may  not  be  amiss  to  mention  here  some  curious  circumstances 
observed  in  the  case  to  which  I  have  just  alluded.  While  this  gentle- 
man's liver  was  enlarging,  there  was  no  tenderness  of  the  right  hypo- 
chondrium  on  pressure.  I  have  observed  the  same  absence  of  tenderness 
in  all  the  cases  of  this  description  I  have  witnessed.  The  gentleman 
could  bear  pressure  over  the  hepatic  region  without  any  inconvenience, 
and  yet  the  liver  was  so  enormously  increased  in  size,  that  its  inferior 
margin  extended  almost  down  to  the  pelvis.  What  is  equally  remark- 
able, he  had  no  fever,  and  the  tongue  was  perfectly  clean  and  moist 
during  the  whole  course  of  the  hepatic  affection.  In  my  observations 
on  a  case  in  the  fever  ward,  I  remarked  a  few  days  since  that  some  per- 
sons were  too  hasty  in  drawing  inferences  from  the  state  of  the  tongue 
as  to  the  existence  of  affections  of  the  digestive  organs.  I  shall  not 
touch  on  this  point,  however,  at  present,  and  shall  merely  observe  that 
this  gentleman's  tongue  was  perfectly  clean  and  moist,  notwithstanding 
VOL.  I.  29 


450  CLINICAL   MEDICINE. 

the  morbid  condition  and  rapid  growth  of  the  hver.  Another  curious 
circumstance  was,  that  during  the  hepatic  affection,  digestion  appeared 
to  go  on  very  well,  at  least  so  far  as  the  formation  and  due  expulsion  of 
fseces  are  concerned.  The  alvine  evacuations  were  regular,  and  the  matter 
discharged  presented  the  form  and  consistence  of  that  which  is  passed 
by  a  person  in  good  health.  But  there  was  a  peculiarity  in  it  to  which 
my  attention  was  first  directed  by  the  patient,  who  was  an  inteUigent 
and  observant  person.  The  cylinder  of  fsecal  matter  was  composed  of 
parts  differing  in  colour  and  appearance :  two  or  three  inches  consisted 
of  pale  clay-coloured  substance ;  and  immediately  after  this  another  por- 
tion, of  about  the  same  length,  was  observed,  presenting  the  ordinary 
bilious  or  brown  colour  of  natural  excrement ;  and  then  again  another 
mass  of  clay-coloured  matter,  without  any  obvious  trace  of  bile.  This 
appearance  I  have  now  frequently  witnessed ;  and  the  inference  to  be 
drawn  from  it  is  this, — that  in  such  forms  of  hepatic  disease  the  functions 
of  the  liver  are  performed,  as  it  were,  intermittently;  it  secretes  bile 
during  a  certain  period  of  the  digestive  process,  then  stops,  and  then 
secretes  again. 

This  peculiarity  is  noticed  in  many  diseases  of  the  liver ;  and  it  is 
important  to  remark,  in  attempting  to  explain  the  rationale  of  these 
hepatic  affections,  that  in  no  disease  of  the  liver  is  this  symptom  more 
frequently  observed  than  in  the  scrofulous.  Scrofulous  disease  of  the 
liver  is  that  state  in  which  there  is  an  increase  of  size  in  the  organ,  with 
induration  and  imperfect  secretion,  but  without  any  remarkable  tender- 
ness. Tliis  condition  in  children  is  accompanied  by  irritability  of  the 
digestive  organs,  fretfulness,  emaciation,  loss  of  sleep,  and  impaired  nu- 
trition. The  little  patient  becomes  what  is  termed  "  pot-bellied/^  and 
labours  under  thirst,  debility,  and  febrile  excitement.  This  has  been 
frequently  called  remittent  fever,  and  disease  of  the  mesenteric  glands, 
but  in  my  opinion  unjustly.  It  is  only  a  form  of  general  cachexy  con- 
nected with  the  scrofulous  diathesis,  affecting  secretion  and  nutrition  in 
general,  and  the  digestive  and  biliary  systems  in  particular.  It  would 
be  quite  wrong  to  imagine,  that  in  this  form  of  disease  the  liver  is  the 
cause  of  the  whole  train  of  morbid  phenomena ;  it  is  merely  affected  in 
common  with  other  organs,  and  forms  only  an  individual  feature  in  the 
group  of  symptoms. 

Now,  in  this  form  of  scrofulous  cachexy,  where  you  have  diarrhoea, 
emaciation,  fever,  thirst,  and  restlessness,  the  liver  is  frequently  affected 
in  the  manner  already  described ;  and  in  the  loose  stools  of  such  a  child, 
you  will  find  one  part  bilious,  another  part  clay-coloured ;  they  will  be 
yellow  this  day,  and  pale  the  next,  accordingly  as  the  liver  secretes  bile  or 
suspends  its  functions.     But  in  this  instance,  I  repeat  that  the  liver  is 


THE    CONNEXION    BETWEEN    DISEASES    OF    DIFFERENT    ORGANS.       451 

only  one  of  many  organs  affected  by  the  same  general  cachexy.  Could 
we  ascertain  the  derangements  of  other  secreting  organs  with  the  same 
facility,  it  is  very  probable  we  should  find  similar  evidences  of  the  morbid 
influence  which  pervades  the  whole  system. 

This  view  of  the  question  shows,  that  you  are  not  to  expect  to  succeed 
in  removing  the  disease  by  the  use  of  calomel  or  any  other  mercurial 
preparation.  Many  of  those  persons  whose  practice  is  little  better  than 
routine,  when  called  to  treat  a  case  of  this  description,  first  examine  or 
inquire  as  to  the  nature  of  the  alvine  evacuations,  and  fixing  on  the  sin- 
gle symptom  of  deficiency  of  bile,  immediately  prescribe  calomel,  to  be 
repeated  or  continued  until  the  secretion  of  the  liver  is  established ;  but 
they  forget  that  this  state  of  the  biliary  system  depends  on  the  general 
state  of  health,  and  that  the  absence  of  the  bile  is  the  consequence,  and 
not  the  cause  of  the  disease.  Almost  all  the  organs  of  the  body  are 
affected ;  and  though  calomel  may  restore  the  secretion  of  the  liver  for 
a  time,  it  cannot  bring  back  the  organ  to  its  natural  state,  or  cure  the 
disease.  The  malady  is  to  be  remedied  in  a  different  way:  the  secretions 
(and  that  of  the  liver  among  the  rest)  are  to  be  improved  by  change  of 
air,  by  an  appropriate  diet,  by  exercise,  tepid  or  cold  bathing,  and  the 
use  of  those  remedies  which  are  adapted  to  modify  or  correct  that  state 
of  the  system  on  which  the  general  derangement  depends. 

An  observation  of  such  cases  has  led  me  to  a  train  of  reflection  res- 
pecting the  occur|;ence  of  the  same  order  of  symptoms  in  persons  who 
have  been  injured  by  the  abuse  of  mercury.  Many  persons  who  get 
venereal,  employ  mercury  injudiciously,  and  fall  into  what  has  been 
termed  mercurial  cachexy,  in  which  there  is  a  general  unhealthy  state 
of  the  organs.  A  patient  who  has  fallen  into  this  state  very  closely 
resembles  a  scrofulous  person,  and  is  apt  to  labour  under  the  same  ema- 
ciation, in\paired  nutrition,  irritability,  feverishness,  and  the  same  sort  of 
cutaneous,  glandular,  and  periostitic  affections.  The  chronic  mercurial 
cachexy  is  very  like  the  scrofulous,  and  attacks  very  nearly  the  same 
organs  and  tissues.  Hence  the  difficulty  of  curing  affections  of  the  liver, 
and  other  organs,  when  they  are  the  result  of  this  depraved  habit.  This 
is  the  key  to  the  explanation  of  those  horrible  ravages  which  we  fre- 
quently witness  in  cases  of  venereal  disease  complicated  with  mercurial 
cachexy — a  state  of  constitution  which  is  closely  allied  to  the  scrofulous. 
You  will  frequently  meet  with  this  consecutive  affection  of  the  liver  in 
cases  of  morbus  coxae,  where  the  patient  has  been  labouring  for  years 
under  ulceration  of  the  joint.  The  growth  of  the  rest  of  the  body  appears 
checked,  the  patient  is  stunted  and  emaciated,  while  the  liver  increases 
rapidly  in  size.  It  was  from  observing  the  occurrence  of  liver  disease 
in  persons  labouring  under  the  scrofulous  cachexy,  that  my  attention  was 


452  CLINICAL   MEDICINE. 

first  turned  to  its  occurrence  in  persons  broken  down  by  long  or  injudi- 
cious courses  of  mercury. 

One  word,  gentlemen^  as  to  the  curability  of  hepatic  affections  of  this 
kind.  I  believe  that  it  is  always  an  unpromising  form  of  disease  ;  but 
persons  of  originally  good  constitution,  and  under  the  age  of  thirty,  will 
generally  escape,  if  treated  judiciously,  and  with  proper  care  and  attention. 
Some  months  ago  I  attended,  wdth  Sir  Henry  Marsh,  a  young  gentleman 
labouring  under  this  affection,  as  a  consequence  of  the  abuse  of  mercury. 
We  found  him  greatly  emaciated,  and  labouring  under  considerable  en- 
largement of  the  liver,  with  commencing  ascites.  He  had  also  great 
determination  of  blood  to  the  abdomen,  diarrhoea,  and  hemorrhoids. 
By  strict  attention  to  his  bowels,  a  well-regulated  diet,  change  of  air,  and 
the  use  of  taraxacum,  conium,  and  hydriodate  of  potash,  he  was  ulti- 
mately cured,  after  an  illness  of  nearly  two  years,  during  which  the  liver 
had  grown  to  an  enormous  size.  I  may  state,  that  he  is  at  present  in 
good  health,  and  that  the  liver  is  nearly  reduced  to  its  natural  dimensions ; 
this  gentleman^s  age  is  about  four-and-twenty. 

I  observed  one  circumstance  in  the  progress  of  this  case  which  is 
worth  noting.  He  was  suddenly  attacked  with  a  papular  form  of  pur- 
pura, accompanied  by  much  tingling  and  itchiness,  and  answering  to  the 
description  given  of  Purpura  urticans.  This  peculiar  eruption  was  very 
troublesome  at  night,  and  formed  several  successive  crops  which  altogether 
lasted  a  month.  It  occupied  the  extremities,  upper  and  lower,  and  was 
very  abundant  on  the  latter.  The  gentleman  wore  a  bandage  to  relieve 
a  varicose  state  of  the  veins  of  the  left  leg.  !Now  the  eruption  never 
appeared  in  the  parts  subjected  to  the  pressure  of  the  bandage,  although 
it  was  very  thick  immediately  below  and  above  these  parts. 

I  may  observe,  that  it  is  entirely  as  the  result  of  the  cachectic  habit 
this  enlargement  of  the  liver,  which  I  have  now  been  speaking  of,  is 
observed.  I  have  assumed  this  principle  as  the  basis  of  my  argument, 
and  I  think  it  is  founded  in  fact  and  truth.  It  is  also  curious  to  ob- 
serve, that  the  same  cachectic  state  which  gives  rise  to  emaciation  and 
decay  of  the  body,  generally  occasions  hypertrophy  of  some  particular 
organ.  What  we  most  commonly  observe  in  such  conditions  is,  ge- 
neral wasting  of  the  system,  accompanied  by  increased  morbid  imtri- 
tion  in  certain  organs.  This  appears  to  be  the  general  law.  You  per- 
ceive that  in  the  explanation  I  have  given,  I  have  supposed  that  en- 
larged liver  is  the  result  of  a  general  cachectic  state  of  the  system,  and 
it  is  of  importance  to  recollect,  that  this  state  may  be  brought  on  by 
the  injudicious  exhibition  of  mercury,  or  by  carrying  mercurialization 
farther  than  the  constitution  will  bear.  In  this  instance,  wt.  are  compelled 
to  allow,  that  our  practice  may  furnish  weapons  to  be  turned  against  us 


THE    CONNEXION    BETWEEN    DISEASES    OF    DIFFERENT   ORGANS.       453 

by  the  disciples  of  homeopathy.  It  cannot,  however,  be  denied,  that 
the  immoderate  use  of  mercury  has  been  productive  of  liver  disease. 
The  late  Mr.  Hewson  pointed  out  this  to  the  attention  of  those  who 
visited  the  Lock  Hospital  while  under  his  care.  At  this  period  it  was 
the  custom  to  salivate  every  patient,  and  keep  him  under  the  full  mer- 
curial influence  for  a  month  or  two ;  and  it  frequently  happened,  that 
just  as  the  mercurial  course  was  finished,  the  patient  got  disease  and 
enlargement  of  the  liver.  Were  I  inclined  to  theorise,  I  might,  per- 
haps, offer  some  fanciful  hypothesis  in  explanation  of  this  occurrence, 
and  might  trace  some  connexion  between  the  stimulant  effects  of  mer- 
cury on  the  liver,  and  the  subsequent  hypertrophy.  I  shall,  however, 
content  myself  at  present  with  noticing  the  fact,  and  leave  the  explana- 
tion to  my  juniors,  who  always  explain  matters,  according  to  my  obser- 
vation, much  more  readily  than  their  seniors. 

There  are  also  other  diseased  states  of  the  system,  in  which  we  have 
enlargement  and  morbid  alteration  of  the  liver.  I  can  point  out  to 
you  four  different  states  of  the  system  in  which  hypertrophy  and  disease 
of  the  liver  forms  one  of  the  results  of  the  general  affection  of  the 
system.  The  next  of  these  to  which  I  shall  direct  your  attention  is 
scarlatina.  Those  who  have  attended  the  wards  during  the  past  month 
have  seen  examples  of  this.  We  have  observed  during  the  past  week 
two  patients  labouring  under  scarlatina,  who  got  disease  of  the  liver  and 
jaundice.  One  of  the  patients,  a  little  boy,  was  attacked  with  the  dis- 
ease  in  an  extremely  violent  form,  accompanied  by  high  fever,  and  a 
very  remarkable  eruption.  In  a  few  hours  after  the  exanthema  ap- 
peared, the  entire  cutaneous  surface  was  dyed  of  a  brilliant  red ;  in  fact, 
the  skin  looked  as  if  it  had  been  painted  over,  and  there  was  not  a 
single  spot  free.  In  cases  of  this  kind  the  violence  of  the  cutaneous 
inflammation  is  sufficient  to  kiU,  without  any  other  unfavourable  com- 
plication j  and  the  patient  seldom  lives  more  than  three  or  four  days. 
You  observed  in  this  case,  that  the  whole  epidermis  peeled  off.  But 
what  I  wish  to  direct  your  attention  to  is,  that  this  boy  after  two  days 
had  evident  symptoms  of  disease  and  enlargement  of  the  liver.  A 
young  man,  in  the  same  ward,  had  also  an  attack  of  scarlatina,  but  in  a 
milder  form.  On  the  third  day  he  likewise  got  inflammation  of  the 
liver,  but  was  cured  by  general  and  local  antiphlogistic  treatment. 

In  a  previous  lecture  I  have  explained  to  you  that  scarlatina  is  one 
of  those  diseases  in  which  a  train  of  unfavourable  sequelae  are  apt  to 
remain  after  the  removal  of  the  original  complaint.  Persons,  after  re- 
covering from  the  exanthematous  fever,  wiU  sometimes  get  into  a  bad 
state  of  health,  and  instead  of  convalescing,  become  restless  and  fever- 
ish towards  evening,  have  an  irritable  jerking  pulse,  hot  skin^  derange- 


454  CLINICAL   MEDICINE. 

ment  of  the  digestive  organs,  diminislied  urinary  secretion,  and  finally 
become  dropsical.  'Now,  from  observing  the  supervention  of  hepatic  dis- 
ease in  such  cases,  both  in  hospital  and  private  practice,  my  attention  has 
been  directed  to  the  liver ;  and  I  never  omit  making  an  examination  of 
that  organ  when  called  to  treat  those  symptoms  which  are  looked  upon 
as  the  sequelae  of  scarlatina.  In  many  of  these  patients  I  have  found 
the  liver  in  a  state  of  inflammation  of  rather  a  chronic  character,  and 
without  any  of  that  remarkable  pain  or  tenderness  which  characterizes 
acute  hepatitis.  But  still  it  was  inflamed,  as  proved  by  the  benefit  de- 
rived from  local  antiphlogistic  means;  and,  moreover,  its  condition 
appeared  to  retard  and  prevent  convalescence. 

Not  long  since,  a  friend  of  mine,  a  very  intelligent  practitioner,  who 
was  attending  a  case  of  this  description,  and  had  tried  a  variety  of  re- 
medies without  any  benefit,  was  very  much  surprised  when  I  drew  down 
the  bed-clothes  and  showed  him  that  the  liver  was  diseased.  He  had 
not  thought  of  the  existence  of  anything  like  hepatic  affection,  and 
was  very  much  surprised  that  his  treatment  had  proved  so  ineffectual. 
By  the  use  of  leeches  to  the  right  hypochondrium,  the  employment  of 
mercury,  and  a  proper  regulation  of  diet,  the  patient  was  soon  reheved, 
and  the  fever,  thirst,  and  anasarca,  quickly  disappeared.  In  cases  of 
this  kind,  the  hepatic  affection  is  the  result  of  the  general  inflammatory 
diathesis,  superinduced  by  scarlatina.  You  are  all  aware  that  nothing 
is  more  common  after  scarlatina,  than  inflammation  of  various  organs. 
Thus  some  persons  are  attacked  mth  pleuritis,  some  with  pneumonia, 
others  with  inflammation  of  the  liver.  Many  persons  continue  in  a 
valetudinary  state  after  the  eruption  has  declined ;  they  do  not  conva- 
lesce according  to  our  expectations ;  the  pulse  remains  rather  quicker 
than  natural ;  the  bowels  are  deranged ;  the  appetite  bad ;  thirst  ur- 
gent ;  and  urine  scanty.  In  many  of  these  cases  you  will  find  that 
there  is  a  species  of  chronic  hepatitis  going  on,  wliich  keeps  up  the 
feverishness,  and  retards  convalescence.  This  is  a  point  of  great  im- 
portance, to  which  I  am  the  more  anxious  to  draw  your  attention, 
because  even  the  latest  writers  on  scarlatina  have  either  entirely  omitted 
or  very  insufficiently  noticed  it. 

There  is  another  organ  whose  morbid  affections  frequently  impHcate 
the  liver ;  I  allude  here  to  the  heart.  I  have  already  spoken  of  cer- 
tain cachectic  states,  in  which  the  liver  becomes  enlarged  and  hyper- 
trophied  as  the  result  of  the  general  derangement  of  the  system.  In 
the  present  case  the  hypertrophy  and  disease  of  the  liver  originate  in 
a  morbid  condition  of  the  heart ;  this  is  a  very  frequent  cause  of  he- 
patic derangement.  You  have  an  example  of  it  at  present  in  the  chro- 
nic ward,  in  the  case  of  a  poor  man  labouring  under  bronchitis  of  long 


THE    CONNEXION    BETWEEN    DISEASES    OE   DIFFERENT   ORGANS.       455 

standing,  with  disease  of  the  heart,  dropsy,  and  enlargement  of  the 
liver.  In  cases  of  this  description  it  is  a  matter  of  some  difficulty  to 
determine  in  what  organ  the  morbid  sequence  commences ;  for  where 
many  diseases  coexist,  it  is  not  easy  to  ascertain  how  they  are  related 
to  each  other  as  cause  and  effect.  I  have,  however,  had  several  oppor- 
tunities of  observing  the  progress  of  the  disease  from  the  commence- 
ment, and  the  manner  in  which  the  different  organs  become  success- 
ively implicated. 

Some  time  ago  there  occurred  a  remarkable  example  of  tliis  form  of 
hepatic  affection  in  a  relative  of  mine,  aged  14,  who,  in  consequence  of 
exposure  to  cold,  was  attacked  with  rheumatic  inflammation  of  the 
joints,  of  a  very  intense  character.  Owing  to  a  want  of  proper  care, 
the  disease  was  allowed  to  go  on  unchecked,  and  metastasis  to  the  peri- 
cardium took  place.  I  happened  to  be  out  of  town  at  the  time,  and 
he  had  no  advice  or  assistance  for  nearly  twenty-four  hours.  Pericar- 
ditis of  a  violent  character  became  developed,  and  it  was  only  by  the 
most  energetic  treatment  that  he  escaped  with  his  life.  He  had  peri- 
carditis with  effusion,  and  all  the  physical  signs  and  symptoms  of  car- 
ditis. After  the  acute  symptoms  were  removed,  the  signs  of  adhesion 
of  the  pericardium,  hypertrophy,  and  partial  valvular  disease,  continued ; 
and  for  a  long  time  the  heart's  action  was  invariably  accompanied  by  a 
loud  bruit  de  soufflet.  These  affections  were  followed  by  dyspnoea  and 
increased  action  of  the  heart.  But  this  was  not  all.  He  next  got  in- 
flammation of  the  testicle,  and  finally  chronic  hepatitis  with  enlarge- 
ment. The  liver  grew  to  a  very  considerable  size ;  it  continued  to  en- 
large for  about  seven  months ;  and  altogether  he  laboured  under  a  chronic 
form  of  hepatitis  for  more  than  a  year.  At  last  the  disease  yielded  to 
treatment,  and  he  recovered  completely. 

Tliis,  you  will  say,  was  a  fortunate  termination ;  but  in  young  per- 
sons the  powers  of  nature  often  act  in  a  very  remarkable  manner  in 
remedying  or  removing  disease,  and  cures  are  sometimes  effected  in 
such  patients  which  it  would  be  quite  absurd  to  expect  in  persons  ad- 
vanced in  life.  After  having  laboured  under  a  long  train  of  diseases, 
and  having  contiimed  an  invalid  for  nearly  five  years,  this  young 
gentleman  at  last,  owing  to  his  youth  and  favourable  constitution,  sur- 
mounted all  his  maladies,  and  is  at  present  as  strong  and  healthy  as 
any  person  I  am  acquainted  with.  In  this  instance  the  chronic  hepa- 
titis was  the  result  of  the  pericarditis,  whicli  formed  the  first  link  in 
the  chain ;  and  for  the  space  of  a  year  this  young  gentleman  continued 
to  labour  under  an  affection  of  the  liver,  the  result  of  disease  com- 
mencing in  the  heart.  This  is  a  morbid  sequence  very  frequently  ob- 
served.    You  have  pericarditis,  accompanied  by  inflammation  of  the 


456  CLINICAL    MEDICINE. 

lining  membrane  of  the  heart,  partial  disease  of  the  valves,  hypertrophy 
of  the  muscular  substance,  and  then  enlargement  and  induration  of  the 
Hver. 

This  is  a  very  common  complication,  and  deserves  your  most  particu- 
lar attention.  When  you  see  a  patient  whose  appearance  indicates  dis- 
ease of  the  heart — who  has  swelling  of  the  face,  dyspnoea,  lividity  of  the 
lips,  and  turgescence  of  the  cutaneous  vessels — in  fact,  that  peculiar  ex- 
pression of  countenance  which  at  once  informs  the  practised  observer 
that  the  patient  is  labouring  under  disease  of  the  heart,  you  should  not 
neglect  to  inquire  after  the  condition  of  the  liver,  for  in  such  cases  it  is 
very  frequently  in  a  state  of  chronic  disease.  I  pointed  out  this  circum- 
stance some  time  since,  in  the  case  of  a  late  surgeon,  Mr.  M.,  and 
directed  the  attention  of  the  medical  gentlemen  engaged  in  the  treat- 
ment of  the  case  to  the  liver,  in  which  no  one  had  suspected  the  exist- 
ence of  disease.  Eecollect,  therefore,  that  in  many  cases  of  disease  of 
the  heart  you  will  also,  on  examination,  find  disease  of  the  hver,  pro- 
duced, as  far  as  I  can  judge,  in  the  majority  of  instances,  by  disease  of 
the  heart ;  at  least,  I  think  I  have  never  seen  any  case  in  which  the 
hepatic  affection  had  the  initiative,  and  seemed  to  have  brought  on  the 
organic  affection  of  the  heart.  In  Mr.  M."'s  case,  and  several  others 
which  I  had  an  opportunity  of  watching  from  the  commencement,  I 
have  no  doubt  that  the  disease  of  the  liver  was  secondary,  and  that  the 
morbid  sequence  commenced  with  the  heart.  I  am  quite  convinced  that 
disease  of  the  liver  may  give  rise  to  functional  derangement  of  the 
heart ;  for  whatever  impairs  secretion  and  deranges  digestion,  will  give 
rise  to  palpitations,  tendency  to  syncope,  and  other  phenomena  of 
functional  disease  of  the  heart ;  but  I  have  never  seen  any  example  of 
organic  disease  of  the  heart  as  the  result  of  disease  of  the  liver. 

It  is  of  some  importance  to  be  aware  of  this  complication ;  for  in 
treating  the  disease  of  the  heart  you  must  also  attend  to  the  hepatic 
affection,  because  it  has  a  tendency  to  aggravate  and  confirm  the  cardiac 
symptoms.  This  affection,  however,  is  not  to  be  looked  upon  as  acute, 
or  even  subacute  hepatitis.  There  is  scarcely  any  pain  of  the  side  or  ten- 
derness present,  and  the  patient  is  not  always  jaundiced ;  it  appears  to 
be  scarcely  anything  more  than  congestion,  causing  hypertrophy  and 
chronic  morbid  growth.  I  shall  not,  however,  speak  too  positively  on 
the  subject,  as  the  difference  between  hypertrophy  and  inflammation  of 
a  low  and  obscure  character  cannot  be  easily  determined.  I  am  glad  to 
find  that  the  subject  I  am  now  discussing  has  been  taken  up  by  so  able 
an  observer  as  Dr.  Bright,  who,  in  the  third  number  of  Guy's  Hospital 
Eeports,  p.  605,  has  made  some  excellent  remarks  on  the  influence  of 
heart  disease  in  producing  congestion  of  the  hver. 


THE    CONNEXION   BETWEEN    DISEASES    OF   DIFFERENT   ORGANS.      457 

There  is  another  disease  in  which  derangement  of  the  Hver  is  a  com- 
mon symptom,  and  I  bring  it  forward  chiefly  for  the  purpose  of  render- 
ing the  subject  under  discussion  more  complete,  as  it  is  an  occurrence 
well  known  to  practitioners,  and  sufficiently  dwelt  on  in  medical  books. 
I  allude  to  that  affection  of  tlie  liver  which  is  observed  in  xases  of  inter- 
mittent fever.  Ague  frequently  produces  a  pow^erful  determination 
to  internal  organs,  particularly  the  liver  and  spleen,  and  if  treated 
badly,  or  unsuccessfully,  is  apt  to  bring  on  disease  of  the  liver.  The 
organ  becomes  congested,  hypertrophied,  and  indurated,  and  presents  a 
condition  somewhat  analogous  to  that  which  supervenes  on  disease  of 
the  heart,  or  results  from  the  cachectic  state  of  constitution  produced 
by  mercury  or  scrofula. 

The  next  form  of  organic  derangement  which  I  shall  briefly  touch  on, 
is  that  of  the  spleen.  It  is  of  advantage  to  place  cognate  affections  be- 
side each  other,  for  the  purpose  of  comparison;  by  doing  so,  we  fre- 
quently derive  many  instructive  and  useful  analogies.  Besides,  we  have 
had  a  remarkable  case  of  enlargement  of  the  spleen  in  our  wards  at 
the  same  time  we  had  the  cases  of  hepatic  disease  to  which  I  have 
alluded. 

The  circumstances  under  wliich  enlargement  of  the  spleen  takes  place, 
differ  in  many  points  from  those  which  determine  hypertrophy  of  the 
liver.  We  have  but  few  examples  of  inflammation  of  the  spleen,  while 
the  cases  in  which  enlargement  and  congestion  of  that  organ  take  place 
are  numerous.  Erom  the  peculiarity  of  its  anatomical  structure,  the 
spleen  is  very  apt  to  become  suddenly  enlarged.  Like  the  liver,  it 
may  become  indurated  and  hypertrophied  from  intermittent,  or  from 
some  general  disease  affecting  the  system,  and  thus  lead  to  a  train 
of  secondary  phenomena ;  the  most  remarkable  of  which  is  dropsy. 
But  there  is  one  peculiar  symptom  attending  enlargement  of  the 
spleen,  which  I  have  frequently  pointed  out  to  the  attention  of  the 
class,  as  observed  at  least  in  two-thirds  of  the  cases,  and  of  which  we 
had  an  excellent  specimen  in  the  patient  under  treatment  in  the  chronic 
ward. 

The  history  of  this  symptom  is  the  more  curious  as  showing  a  re- 
markable uniformity  in  the  phenomena  of  a  peculiar  disease  at  very 
distant  periods  of  time.  This  is  seen  by  comparing  the  most  recent 
descriptions  of  Indian  splenitis,  as  given  in  an  able  analysis  of  Voight's 
work  on  the  Spleen,  in  the  British  and  Foreign  Medical  Review j  and 
the  description  of  enlargement  and  disease  of  the  spleen  given  by 
Aretseus.  The  ancients,  it  is  true,  cannot  be  now  considered  as  autho- 
rities to  be  followed  either  in  pathology  or  practice ;  for-  they  were 
ignorant  of  many  of  the  most  important  facts  connected  with  the  healthy 


458  CLINICAL   MEDICINE. 

and  diseased  states  of  the  human  body.  In  consequence  of  their  inac- 
curate anatomical  notions,  they  were  unable  to  appreciate  or  describe 
many  of  those  details  which  now  enrich  the  domain  of  pathological  ana- 
tomy ;  their  writings,  however,  are  invaluable  in  many  respects,  as  con- 
taining admirable  descriptions  of  disease  which  still  continue  to  affect 
the  human  body,  and  as  recording  certain  groups  of  symptoms  which 
are  still  associated.  A  comparison  of  their  descriptions  with  those  of 
modern  times,  cannot  fail  to  be  extremely  curious,  and  may  even  prove 
highly  instruptive ;  for  if  we  find  that  certain  internal  affections  have, 
from  the  most  remote  antiquity  up  to  the  present  period,  been 
generally  accompanied  by  peculiar  derangements  of  distant  parts,  we 
are  authorized  in  considering  this  connexion  to  be  something  more 
than  accidental,  and  consequently  we  may  be  led  to  discover  relations 
between  organs  generally  believed  to  be  quite  unconnected  with  each 
other. 

Thus,  some  years  since,  I  had  three  patients  in  succession  under  my 
care,  who  laboured  under  chronic  enlargement  of  the  spleen,  who  were  all 
affected  with  a  similar  soft  of  cachexy,  and  had  all  the  same  affection 
of  the  skin — namely,  superficial  ulceration  of  the  legs.  This  coinci- 
dence forcibly  arrested  my  attention,  and  I  was  still  more  struck  with 
the  observation,  on  finding  that  Aretseus  had  noticed  this  very  circum- 
stance in  his  admirable  description  of  splenitis.  "If  (says  he),  the 
spleen  does  not  suppurate,  but  becomes  chronically  enlarged,  then  the 
patients  lose  their  appetite,  and  become  cachectic,  swollen,  and  of  an 
unnatural  colour,  while  the  surface  of  the  body  manifests  a  disposition 
to  ulcerate,  particularly  on  the  legs  :  the  ulcers  are  hollow,  round,  livid, 
sanious,  and  difficult  to  heal."'^  This  description  agrees  precisely  with 
the  cases  to  which  I  have  already  referred,  and  it  coincides,  in  a  very 
remarkable  manner,  with  the  account  lately  given  by  Dr.  Yoight,  of 
chronic  disease  of  the  spleen,  as  it  occurs  in  India.  He  observes,  that 
the  cachexy  connected  with  the  Splenalgia  Bengalensis  frequently 
manifests  itseK  by  a  tendency  to  ulceration ;  the  disposition  to  which  is 
so  great,  that  leechbites  and  blisters  occasionally  give  rise  to  foul  or 
phagedenic  ulcers,  which  under  certain  circumstances,  as  where  the 
patient  has  used  mercury  and  is  residing  in  a  swampy  district,  will 
sometimes  run  on  to  a  fatal  termination.  It  is  also  curious,  that  the 
predisposing  causes  of  the  different  varieties  of  chronic  enlargement 
of  the  spleen,  as  given  by  Voight,  are  exactly  the  same  as  those 
detailed  by  Aretseus ;  and  both  writers  correspond  in  their  statements 
as  to  the  age  and  habits  of  life  of  persons  most  liable  to  this  disease, 
as  well  as  the  nature  of  the  locality  and  the  season  of  the  year  most 
favourable   to    its  production.     This  agreement  between  authors  se- 


THE    CONNEXION   BETWEEN    DISExiSES    OE    DIFFERENT    ORGANS.       459 

parated  from  each  other  by  so  many  centuries,  and  who  describe  the 
disease  as  it  occurred  in  different  regions,  and  among  different  races 
of  mankind,  is  extremely  curious,  and  exhibits  a  very  remarkable 
example  of  the  identity  of  the  morbid  phenomena  produced  by  the 
same  causes. 

Prom  the  observations  I  have  made  in  this  lecture,  you  must  perceive 
the  advantage  the  physician  gains  from  a  knowledge  of  this  connexion 
between  the  diseases  of  different  organs,  how  much  precision  it  adds  to 
his  practice,  and  what  facility  it  gives  prognosis.  Additional  investiga- 
tions are  much  wanted  on  this  subject ;  but  based,  as  to  prove  useful 
they  must  be,  on  the  accumulation  of  facts  derived  from  experience, 
much  difficulty  lies  in  the  way  of  their  being  undertaken. 


460 


LECTUEE  XXXI. 


GOUT. 


I  shall  in  the  present  lecture  make  a  few  remarks  on  certain  varieties  of 
gout,  of  which  I  have  recently  seen  several  singular  examples,  premising 
some  observations  on  constitutional  inflammation  in  general. 

There  is  no  proposition  in  pathology  better  established  than  that 
there  exist  several  constitutional  affections  capable  of  generating  and 
modifying  local  inflammatory  action ;  and  that  local  inflammations,  de- 
pending on  a  constitutional  cause,  are  subject  to  very  difi'erent  laws 
from  those  which  regulate  the  phenomena  of  common  inflammation. 

Another  fact  of  equal  importance  in  many  points  of  view  is,  that 
local  inflammations  depending  on  a  constitutional  cause  differ  remark- 
ably from  each  other,  and  in  general  present  specific  characters  easily 
recognized.  Thus,  local  affections  arising  from  scrofula  are  not  likely 
to  be  confounded  with  those  depending  on  gout  or  rheumatism,  and 
the  inflammations  produced  by  syphilis  and  other  animal  poisons  exhibit 
peculiarities  by  which  their  respective  origin  and  nature  may  be  satis- 
factorily ascertained.  It  must,  however,  be  admitted,  that  although 
advanced  considerably  in  our  knowledge  of  the  phenomena  of  local 
disease  depending  on  a  constitutional  cause,  the  subject  stiU  displays  a 
wide  field  for  investigation,  and  many  points  of  much  importance  in 
pathology  and  practice  require  stiU  further  investigation. 

Professor  Cayol,  in  his  Lemons  Or  ales,  has  made  some  observations 
on  this  subject  weU  worthy  of  attention.  Speaking  of  the  dependence 
of  local  disease  on  constitutional  causes,  he  says,  "  II  faut  necessaire- 
ment  conclure  que  les  degenerations  organiques  ne  sont  pas  cause,  mais 
effet.  Et  des  lors,  nous  sommes  fondes  a  vous  dire,  qu'au  lieu  d'user 
votre  vie  a  chercher  toujours  queUes  sont  les  degenerations  organiques 
et  les  alterations  de  texture  qui  produisent  les  symptomes  des  maladies, 
il  serait  bien  temps  de  s'inquieter  un  pen  de  savoir  ce  qui  prod/uit  ces 
degenerations  elles  memes,  en  etudiant  serieusement  les  caracteres,  la 


GOUT.  461 

marche,  et  la  tendance  des  actes  vitaux  qui  les  preparent,  et  qui  les 
produisent  reelmeni." 

There  is  one  fact  connected  with  local  inflammation  depending  on  a 
constitutional  cause  not  sufficiently  noticed^  namely,  that  certain  affec- 
tions of  this  kind  are  sometimes  remarkably  fugitive  and  transient. 
We  are  accustomed  to  regard  the  process  of  inflammation,  whether 
common  or  specific,  as  one  which  generally  lasts  for  some  days ;  but  it 
occasionally  happens,  that  a  peculiar  diathesis  will  give  rise  to  local 
affections  having  the  characters  of  inflammation,  and  which  run  their 
course  and  terminate  in  the  space  of  a  few  hours.  This  observation, 
which  should  be  borne  in  mind  in  the  investigation  of  diseases  con- 
nected with  the  general  habit,  will  serve  to  explain  some  of  the  ano- 
malies which  strike  us  occasionally  in  the  study  of  constitutional 
maladies. 

The  first  instance  of  this  kind  that  came  under  my  notice  occurred 
in  the  case  of  a  florid  healthy-looking  boy,  aged  six  years,  in  whom, 
on  attentive  examination,  I  was  led  to  suspect  the  existence  of  a  scro- 
fulous taint.  At  the  time  I  saw  him  he  was  subject  to  a  sudden  and 
rapid  formation  of  bumps,  or  tumours,  on  various  parts  of  his  body — 
sometimes  on  his  arms,  sometimes  on  his  legs,  and  occasionally  on  the 
trunk.  These  circumscribed  tumefactions  were  accompanied  by  a  feel- 
ing of  heat  and  tenderness,  and  apparently  depended  on  local  conges- 
tion, or  effusion  in  the  subcutaneous  cellular  tissue.  But  what  was 
most  remarkable  in  them  was,  they  arose,  ran  through  their  course, 
and  terminated  in  the  space  of  four  or  five  hours ;  they  were  suddenly 
developed,  and  disappeared  with  equal  rapidity.  In  the  course  of  a 
month,  other  more  permanent  inflammations  were  set  up ;  scrofulous 
ophthalmia,  glandular  swellings,  and  ulcers  supervened ;  the  joints  be- 
came affected,  and  the  boy  died  in  about  a  year  and  a  half,  with  all  the 
characteristic  marks  of  the  scrofulous  diathesis.  I  have  detailed  this 
case  before,  and  shall  not  dwell  on  it  any  further  at  present ;  but  it  is 
well  worthy  of  notice,  in  consequence  of  the  very  brief  duration  of  the 
first  local  symptoms. 

Gout  is  another  disease  which  occasionally  exhibits  examples  of  its 
peculiar  inflammation  attacking  various  parts  and  tissues  of  the  body, 
and  that  for  an  extremely  short  period  of  time.  It  is  well  known  that 
persons  of  a  gouty  habit  are  subject  to  sudden  pains  or  twitches,  which 
last  only  for  a  few  minutes,  or  even  seconds.  I  shall  not  stop  here  to 
consider  what  may  be  the  nature  of  these  fugitive  pains ;  I  may  ob- 
serve, that  certain  facts  seem  to  prove,  that  these  pains  are  the  result 
of  a  momentary  congestion.  Thus,  in  various  neuralgic  affections,  and 
in  inflammatory  diseases  in  which  the  nerves  are  considerably  engaged, 


462  CLINICAL   MEDICINE. 

pain  is  suddenly  produced  by  coughing.  If  a  man  labours  under  neu- 
ralgia of  the  frontal  or  facial  nerves,  or  if  he  is  affected  with  sciatica, 
how  are  his  sufferings  increased  when  he  has  unfortunately  at  the  same 
time  a  cough  !  Every  time  he  coughs,  the  affected  nerve  gives  notice 
that  it  feels  the  congestion  by  a  sudden  pain.  Now  the  only  way  in 
which  coughing  can  increase  a  local  pain,  is  by  favouring  local  conges- 
tion ;  that  it  is  capable  of  doing  this  is  proved  by  the  redness  of  the 
face  it  occasions,  as  also  by  the  hemorrhage  from  the  nose,  or  from 
recent  wounds,  which  is  so  often  produced  by  a  fit  of  coughing. 

As  there  can  be  no  doubt,  then,  that  a  momentary  congestion  may 
produce  a  momentary  pain,  we  may  infer  that  in  many  instances  gouty 
twitches  are  owing  to  some  cause  which  determines  an  instantaneous 
congestion  of  the  affected  part.  Sometimes  the  congestion  is  more 
lasting,  and  the  pain  is  proportionally  intense  and  persistent.  Thus, 
the  late  Mr.  Daly,  of  Henry-street,  mentioned  to  me  the  case  of  a  gen- 
tleman, the  lobe  of  whose  ear  was  sometimes  attacked  suddenly  by 
gouty  congestion,  accompanied  by  agonizing  pain,  but  which  never 
lasted  more  than  a  few  hours.  And  I  have  myself  recently  suffered  from 
a  similar  attack  in  the  cartilage  of  the  ear,  which  did  not  last  longer 
than  an  hour,  disappearing  on  the  occurrence  of  gouty  pains  in  the 
fingers. 

This  fact  brings  to  my  mind  a  curious  case  which  some  years  ago 
came  under  the  notice  of  Sir  PhiHp  Crampton,  Mr.  OTerrall,  and  my- 
self. A  young  gentleman  of  fortune  perceived  that  the  pendent  lobes  or 
tips  of  his  ears  were  becoming  elongated ;  they  increased  gradually  in 
such  a  manner  that  he  considered  himself  disfigured  by  their  unseemly 
length,  and  therefore  attempted  their  concealment  by  allowing  his  hair 
to  grow  in  long  curls,  so  as  to  hide  the  ears.  This  gentleman  soon 
afterwards  became  dropsical  and  died ;  and,  on  dissection,  Mr.  O^Ferrall 
found  his  hver  in  a  state  of  fatty  degeneration.  On  slitting  up  the 
elongated  portion  of  the  ears,  he  discovered  that  their  hypertrophy  had 
been  occasioned  by  the  deposition  of  a  large  quantity  of  fat.  The  sub- 
cutaneous adipose  tissue,  and  the  omentum,  were  likewise  much  loaded 
with  fat.  This  observation  is  of  much  importance,  as  teaching  us  that 
fatty  degeneration  may  be  the  consequence  of  a  general  tendency  in  the 
system  to  manufacture  and  deposit  fat  in  the  textures  of  different 
organs.  In  this  point  of  view  the  change  of  structure  in  the  liver  must 
be  regarded  as  an  effect,  and  not  as  a  cause,  of  the  general  derangement 
of  the  system,  and  the  fatal  termination  of  the  case. 

One  of  the  most  remarkable  instances  of  fugitive  inflammation  af- 
fecting various  parts  of  the  body,  which  has  come  under  my  notice, 
occurred  in  the  person  of  a  gentleman  lately  under  my  care.     I  shall 


GOUT.  463 

not  go  through  the  whole  history  of  his  disease,  of  which  he  has  fa- 
voured me  with  a  very  minute  account,,  but  sliall  merely  state,  that  he 
is  of  a  gouty  habit,  has  had  an  attack  of  gout  in  the  stomach,  and  is 
at  present  subject  to  a  gouty  affection  of  a  very  extraordinary  character. 
After  labouring  for  some  time  under  langour  and  weakness,  accompanied 
by  spasms,  pain,  and  sense  of  weight  in  the  stomach,  the  pain  of  the 
stomach  ceases,  and  his  face  begins  to  swell  at  various  points,  generally 
commencing  on  the  forehead,  and  involving  the  cheek  and  eye,  so  as 
to  close  up  the  latter.  He  first  feels  as  if  a  small  current  of  air  was 
directed  on  the  face ;  then,  as  it  were,  the  fillip  of  a  finger,  or  the  bite 
of  a  gnat ;  and,  on  looking  in  the  glass,  he  suddenly  perceives  a  tumour 
rising  on  the  forehead,  which,  in  the  space  of  half  an  hour,  becomes 
as  large  as  a  pigeon\s  egg,  and,  as  he  expresses  it,  moves  down  until 
it  closes  the  eye.  Sometimes  it  attacks  his  lips,  and  other  parts  of  his 
face,  but  never  affects  his  nose.  These  tumours  have  also  appeared  on 
various  parts  of  his  body ;  and  he  observes  in  his  letter  to  me,  that  he 
is  sometimes  led  to  think  that  they  attack  his  stomach  also.  Before 
and  during  an  attack  of  the  face,  which  generally  occurs  on  the  left 
side,  the  discharge  from  the  nostril  of  the  affected  side  ceases. 

But  what  is  chiefly  remarkable  in  tliis  case  is,  the  singular  character 
of  the  local  affection.  The  tumours  arise,  run  through  their  course, 
and  disappear,  in  the  space  of  a  few  hours ;  and  on  the  following  day 
there  is  no  trace  of  their  existence.  Sometimes  the  lips,  inside  of  the 
mouth,  palate,  and  uvula,  are  attacked,  giving  rise  to  very  considerable 
inconvenience.  Were  such  tumours  to  occur  in  the  neighbourhood  of 
the  glottis,  I  need  not  say  that  they  would  be  pregnant  with  danger  of 
no  ordinary  character.  I  may  observe,  that  this  gentleman  has  derived 
great  benefit  from  the  use  of  hydriodate  of  potash,  and  from  decoction 
of  sarsaparilla  with  nitric  acid,  and  that  his  health  is  at  present  much 
improved.  His  case  presents  a  very  curious  example  of  transient  local 
inflammation  depending  on  the  gouty  diathesis. 

Having  touched  on  the  subject  of  anomalous  local  affections  as  con- 
nected with  the  gouty  habit,  I  may  here  refer  to  a  very  singular  affec- 
tion of  the  teeth,  which  I  have  observed  in  individuals  of  a  gouty  dia- 
thesis. The  disease  I  am  about  to  describe,  though  very  singular  and 
remarkable,  has  not  been  noticed  by  practical  writers.  A  few  preli- 
minary remarks  on  the  functions  of  the  dental  nerves  appear  necessary, 
in  order  to  enable  you  to  form  a  more  exact  idea  of  its  nature. 

The  teeth  are  immoveably  fixed  in  the  jaws,  and  consequently  require 
no  nerves  of  motion  so  far  as  they  themselves  are  concerned ;  they  are, 
on  the  other  hand,  abundantly  supplied  with  nerves  derived-  from  the 
fifth  pair — a  nerve  of  sensation,  and  their  nervous  apparatus  is  deve- 


464 


CLINICAL   MEDICINE. 


loped  and  expanded  witliin  their  substance  in  a  manner  which  shows 
that  nature  has  bestowed  a  greater  degree  of  care  on  this  than  on  any 
portion  of  the  nerves  destined  to  perform  the  office  of  touch.  In  this 
respect  they,  to  a  certain  extent,  approach  the  perfection  of  the  nervous 
apparatus  of  the  organs  of  sense  properly  so  called.  In  truth  no  part 
of  the  mechanism  of  the  human  body  seems  more  admirable  than  that 
which  thus  associates  together  in  function  a  soft  nervous  pulp  and  a 
solid  osseous  substance,  and  associated  together  they  assuredly  are,  for 
the  teeth,  though  encrusted  with  a  coat  of  enamel  as  hard  as  steel,  are 
very  delicate  organs  of  touch ;  the  most  minute  bodies,  when  hard,  may 
be  distinctly  felt  if  placed  between  their  edges ;  and  matters  of  more 
yielding  texture,  as  a  leaf  of  paper,  or  a  rose  leaf,  can  be  distinguished 
in  the  same  position. 

The  delicacy  of  touch  enjoyed  by  the  teeth  has  not  attracted  due 
notice,  nor  have  its  uses  been  sufficiently  dwelt  on,  for  to  this  sense 
are  owing  the  ease  and  precision  with  which,  as  instruments,  they  per- 
form their  proper  office  of  cutting,  tearing,  and  grinding  the  food.  It 
is  from  the  feelings  imparted  to  their  edges  that  we  derive  instant  know- 
ledge of  the  situation,  and  many  of  the  physical  properties  of  the  mor- 
sel, such  as  its  hardness,  consistence,  shape,  size,  &c.,  in  consequence 
of  which  it  is  either  at  once  submitted  to  the  action  of  the  teeth,  or  is 
removed  to  be  placed  in  another  part  of  the  mouth,  and  in  a  more  con- 
venient position,  where  teeth  of  a  different  shape  and  form  may  be 
brought  to  bear  on  it.  Without  this  exquisite  sense  of  feeling  one  row 
of  teeth  could  not  act  in  concert  with  the  other,  the  incisors  and  molars 
in  the  under  could  not  adapt  their  cutting  and  grinding  surfaces  to 
those  in  the  upper  jaw,  nor  could  certain  information  be  conveyed  to 
the  muscles  of  the  lower  jaw,  for  the  purpose  of  commanding  the  con- 
secutive motions  they  are  called  on  to  perform. 

In  fact  the  teeth  are  not  merely  cutting  instruments,  but  are  en- 
dowed, as  it  were,  with  intelligence ;  they  are  it  is  true,  assisted  in  ascer- 
taining the  size,  portion,  hardness,  and  other  physical  qualities  of  the 
morsel  by  the  tongue  and  cheeks,  but  they  perform  besides  a  peculiar 
function,  that  of  feeling  the  intimate  texture  of  what  is  submitted  to 
their  immediate  operations,  thereby  warning  us  instantaneously  when 
the  morsel  contains  any  thing  detrimental  to  their  own  substance; 
without  this  sense  of  touch  how.  soon  would  our  teeth  be  chipped  away 
and  worn  by  minute  but  hard  matters,  as  grains  of  sand,  which  no  care 
can  entirely  exclude  from  our  food,  but  which  the  teeth  detect  at  once 
when  in  contact  with  their  edges,  and  which  they  at  once  refuse  to  act 
on.  In  truth  the  teeth  may,  in  this  point  of  view,  be  considered  as  a 
sort  of  fingers  fixed  within  the  mouth,  destined  to  feel,  examine,  and 


GOUT.  465 

adjust  the  morsel  preparatory  to  placing  it  in  tlie  position  most  favour- 
able for  mastication. 

It  is  very  strange  that  no  example  of  paralysis  of  the  dental  nerves 
has  as  yet  been  observed.  This  subject  has  engaged  my  attention  for 
several  years^  and  I  have  been  in  the  habit  of  inquiring  from  all  my 
paralytic  patients  whether  the  sensibility  of  the  teeth  was  lessened,  but 
in  no  one  instance  have  I  been  able  to  detect  any  thing  approaching  to 
loss  of  sensation  in  these  organs,  an  immunity  difficult  to  account  for, 
and  I  believe  unexampled,  for  I  am  not  aware  of  any  other  nerve, 
either  of  sense  or  of  motion,  which  is  not  occasionally  involved  in  the 
progress  of  paralytic  affections ;  nay,  I  have  more  than  once  been 
obliged  to  direct  the  removal  of  teeth  in  hemiplegic  persons  in  conse- 
quence of  toothache  on  the  paralytic  side.  This  immunity  from  pa- 
ralysis, corroborated  by  the  extensive  experience  of  Mr.  M^Clean, 
seems  the  more  surprising  when  we  recollect  how  subject  the  dental 
nerves  are  to  the  opposite  affection,  or  a  morbidly  increased  and  exalted 
state  of  sensibility,  constituting  the  various  forms  of  toothache. 

Some  physiologists  have  been  inclined  to  suppose  that  the  temperature 
of  bodies  is  judged  of  by  other  nerves  than  those  which  are  the  instru- 
ments of  the  sense  of  touch ;  but  it  appears  that  if  other  arguments 
against  this  hypothesis  are  wanting,  the  instance  of  the  teeth  alone 
would  be  sufficient,  for  here  most  undoubtedly  the  sense  of  touch  and 
the  discrimination  of  temperatures  are  both  functions  of  one  and  the 
same  nerve,  for  the  teeth  possess  but  one. 

The  disease,  to  which  I  would  now  direct  attention,  consists  in  an 
insuperable  desire  on  the  part  of  the  patient  to  grind  his  teeth.  This 
desire  originates  in  a  disagreeable,  uneasy  sensation  in  the  teeth  them- 
selves, and  is  for  the  moment  alleviated  by  forcibly  grinding  them  to- 
gether, but  immediately  returns  when  the  patient  ceases  to  perform  this 
action,  which  is  therefore  continued,  when  the  disease  is  confirmed, 
during  the  entire  day.  When  asleep  the  patients  no  longer  grind  their 
teeth,  the  grinding  being  in  all  cases  the  result  of  voluntary  motion.  I 
have  now  become  acquainted  with  the  cases  of  four  persons  so  affected, 
and  it  is  very  remarkable  that  they  were  all  of  a  confirmed  gouty  habit. 
The  first  person  in  whom  I  observed  it  was  my  late  excellent  and 
esteemed  friend  the  Countess  of  Egmont,  in  whom  this  habit  had  be- 
come so  confirmed  that  she  was  impelled  to  indulge  in  it  continually, 
for  the  moment  she  desisted,  the  uneasy  sensation  in  the  teeth  became 
insupportable,  and  consequently  she  was  obhged  to  give  up  all  society 
for  several  years  before  her  death.  The  grinding  was  in  her  case  strong 
and  forcible,  and  having  been  so  long  continued,  at  last  wore  down  her 
teeth  to  the  very  sockets.     I  consulted  several  of  the  most  eminent 

VOL.  I.  30 


466  CLINICAL  MEDICINE. 

surgeons  in  London  on  her  disease,  among  the  rest  Mr.  Abernethy,  but 
none  were  able  to  suggest  any  means  for  its  alleviation.  She  was  so 
thoroughly  convinced  that  some  permanent  cause  of  irritation  existed  in 
the  teeth  themselves,  that  at  different  times  she  had  several  of  them 
drawn  in  hopes  of  procuring  relief,  but  they  were  found  to  be  perfectly 
sound. 

I  was  lately  consulted  by  the  Rev.  Mr.  B.,  likewise  of  a  gouty  habit, 
and  who  is  driven  from  general  society  by  precisely  the  same  affection. 
In  him  the  molar  teeth  are  worn  quite  flat  and  smooth,  and  the  incisors 
and  canine  teeth  have  undergone  a  remarkable  change,  particularly  the 
former,  which  being  constantly  whetted  by  each  other,  have  acquired 
chisel-shaped  edges,  and  are  so  sharp  that  when  he  inadvertently  passes 
his  tongue  over  them,  they  make  an  incised  wound,  like  that  inflicted 
by  a  sharp  knife.  This  gentleman^s  teeth  have  the  enamel  all  worn  off 
the  crowns,  and  consequently  their  surfaces  present  a  section  of  the  in- 
ternal or  osseous  portion  of  the  tooth ;  and  it  is  remarkable  that  in  this 
as  well  as  in  the  other  cases,  the  internal  or  nervous  cavity  of  the  tooth 
is  never  exposed,  but  appears  to  be  filled  up  with  bony  matter,  in  pro- 
portion as  the  process  of  grinding  wears  away  the  crown,  just  as  has 
been  observed  in  the  case  of  old  men,  such  as  sailors,  who  have  been  in 
the  habit  for  many  years  of  chewing  sea-biscuit.  The  same  phenome- 
non has  been  likewise  observed  in  the  teeth,  of  skulls  supposed  to  have 
been  Roman,  from  which  it  has  been  inferred  that  they  had  generally 
subsisted  on  very  hard  food. 

The  third  case  was  that  of  a  young  clergyman  in  the  south  of  Ireland, 
likewise  of  a  gouty  habit,  and  who  was  afflicted  with  tic  doulotireux  of 
several  branches  of  the  fifth  pair,  and,  among  the  rest,  of  the  dental 
nerves  of  the  left  side,  in  him  the  teeth  on  the  left  side  only  were 
ground  down,  and  the  disease  ceased  after  a  continuance  of  two  years. 

The  third  case  I  have  not  seen,  but  the  following  particulars  have 
been  furnished  me  by  Dr.  Battersby. 

"  Henry  W.,  County  Meath,  aged  60,  has  suffered  from  attacks  of 
gout  for  the  last  thirty  years,  which  are  now  so  tedious  and  severe  as  to 
confine  him  to  his  bed  for  at  least  five  months  annually ;  about  three 
years  ago  he  was  observed  gradually  to  get  a  habit  of  grinding  his 
teeth,  which  he  now  does  constantly  while  awake,  and  so  loudly  as  to 
be  heard  in  the  next  room;  he  is  not  concious  of  it  unless  when 
spoken  to,  I  believe ;  and  his  teeth  are  quite  ground  down.  Two 
years  ago  he  had  an  attack  of  what  he  called  gout  in  his  teeth,  and 
wanted  to  have  them  all  pulled  out.^^ 

I  have  now  seen  several  cases  of  this  kind,  and  I  have  observed  that 
they  all  occurred  in  persons  of  the  gouty  diathesis.     The  grinding  of 


GOUT.  467 

the  teeth  continues  for  years  as  a  daily  habit,  and  produces  very  re- 
markable changes  in  the  conformation  of  these  organs,  affecting  some- 
times one  side  of  the  jaw,  sometimes  both ;  so  that  in  confirmed  cases 
we  frequently  find  the  teeth  ground  down  to  the  level  of  the  gums. 
There  is  not  at  present  the  shghtest  doubt  on  my  mind,  that  the  irri- 
table state  of  the  dental  nerves,  which  gives  rise  to  this  irresistible  ten- 
dency to  grind  the  teeth,  depends  chiefly  on  the  existence  of  gout  in 
the  constitution.  I  may  observe,  however,  that  in  many  persons  in 
whom  the  teeth  are  found  worn  nearly  to  the  gums,  there  appears  to  be 
another  cause  in  operation.  Thus,  in  cases  of  indigestion  it  is  not  un- 
usual to  find  the  enamel  of  the  teeth  partially  or  considerably  worn 
away,  long  before  the  natural  time ;  and  in  such  instances  we  used  for- 
merly to  attribute  the  injury  to  the  generation  of  acids  in  the  stomach. 
The  researches  of  Donne  and  Thomson,  however,  have  shown  that  the 
saliva  is  subject  to  very  remarkable  alterations  in  certain  forms  of 
dyspepsia,  and  that  whenever  the  disease  is  accompanied  by  much  irri- 
tation of  the  gastric  mucous  membrane,  and  derangement  of  its  se- 
creting functions,  the  saliva  becomes  extremely  acid,  and,  of  course,  ca- 
pable of  corroding  the  enamel  of  the  teeth.  The  following  case  has 
recently  come  under  the  notice  of  Mr.  Pakenham,  of  Henry-street : — 

A  gentleman,  aged  45,  slightly  made,  but  muscular,  and  born  of 
healthy  parents,  was  attacked  with  shivering  and  loss  of  power  of  the 
right  side  after  a  severe  wetting.  He  recovered  under  appropriate 
treatment ;  but,  about  a  year  afterwards,  began  to  observe  in  himself  a 
tendency  to  grind  his  teeth,  which  gradually  increased  to  such  an  extent 
as  to  prove  a  nuisance  to  himself  and  every  one  about  him.  Under 
these  circumstances  he  consulted  an  eminent  surgeon  in  Dublin,  who 
applied  the  actual  cautery  behind  one  of  his  ears,  slightly  affected  his 
system  with  mercury,  and  extracted  one  of  his  teeth, — all  with  consider- 
ble  relief,  which  lasted  for  about  six  months.  He  then  became  as  bad 
as  ever,  and  applied  to  another  surgeon,  who  tried  iron  in  every  form 
without  success  :  and  subsequently  to  a  third  practitioner,  who  used  in 
addition  leeching,  blistering,  pustulation  with  tartar  emetic  and  various 
other  remedies,  but  without  any  favourable  result.  All  this  time  his  me- 
dical attendants,  so  far  from  suspecting  the  presence  of  gout,  ridiculed 
the  idea  of  its  existence. 

About  three  months  ago,  this  gentleman  came  to  Dublin,  went  to 
dine  at  the  house  of  a  friend,  and  with  some  others,  supped  late  at 
night,  and  drank  some  whiskey  punch.  Next  day  he  had  vomiting, 
purging,  and  epigastric  tenderness,  and  on  the  day  after,  the  ball  of  his 
great  toe  became  swollen,  hot,  and  exquisitely  painful,  leaving  no  doubt 
as  to  the  nature  of  the  affection.     In  this  gentleman's  case  the  grinding 


468  CLINICAL  MEDICINE. 

of  the  teeth  is  not  constant^  but  it  is  always  greatest  when  the  stomach 
is  most  deranged.  The  teeth  in  the  under  jaw  are  all  sound  :  three  or 
four  of  the  molars  of  the  upper  jaw  have  been  extracted.  The  four 
upper  incisors  are  ground  nearly  half  way  through  to  the  gum  on  the 
one  side,  while  the  lower  are  very  little  worn.  By  pressing  the  tongue 
against  the  upper  incisors,  or  by  touching  a  certain  point  of  one  parti- 
cular tooth,  he  can  at  any  time  arrest  the  tendency  to  grind,  and  can 
suspend  it  as  long  as  pressure  is  continued  in  the  manner  just  described. 

Although  I  have  as  yet  been  unable  to  discover  any  mode  of  allevi- 
ating the  sufferings  of  patients  afflicted  with  this  hitherto  undescribed 
disease,  I  have  thought  it  right  to  give  you  the  preceding  short  account 
of  its  chief  symptoms  in  the  hope  that  others  may  be  induced  to  pubhsh 
the  results  of  some  successful  method  of  treatment. 

"With  the  view  of  further  illustrating  the  varieties  of  gout,  I  shall 
detail  the  following,  remarkable  case,  which  came  recently  under  my 
notice  : — The  patient,  a  gentleman  of  large  fortune,  is  of  a  strong  and 
athletic  frame,  about  five  and  thirty  years  of  age,  and  a  member  of  a 
family  subject  to  gout.  He  was  much  addicted  to  field  sports,  and 
accustomed,  in  cold  weather,  to  frequent  immersion  of  his  feet  in  cold 
water,  in  pursuit  of  his  favourite  amusement,  snipe-shooting.  The  con- 
sequence of  this  exposure  has  been,  that  he  has  been  labouring  for  some 
time  under  a  neuralgic  affection  of  the  lower  extremities,  which  com- 
menced in  the  feet  and  ankles,  and  extended  gradually  upwards,  involv- 
ing the  whole  of  the  lower  extremities  as  far  as  the  hips,  and  giving 
rise  to  sufferings  of  a  very  intense  character. 

Eepeated  exposure  of  the  feet  to  cold  seems  often  to  lay  the  founda- 
tion of  Creeping  Paralysis.  Now  in  this  case  there  is  some  dan'ger  that 
the  gentleman,  were  proper  measures  neglected,  may  ultimately  become 
paraplegic,  or  even  generally  paralytic.  I  do  not  bring  tliis  case  for- 
ward as  an  example  of  gouty  pains  gradually  advancing  from  the  extre- 
mities towards  the  spine ;  for  although  I  strongly  incline  to  the  opinion 
that  his  complaint  is  of  a  gouty  nature,  and  although  most  of  his  medi- 
cal advisers  have  suspected  a  gouty  complication,  still  this  is  by  no  means 
a  decided  point ;  but  the  opinion  of  his  usual  attendant.  Dr.  Little,  of 
Sligo,  exactly  agrees  with  mine,  as  he  considers  the  case  to  be  gouty 
neuralgia.  Be  this  as  it  may,  his  case  presents  a  very  interesting  speci- 
men of  creeping  neuralgia,  chiefly  affecting  the  cutaneous  nerves, 
(nerves  exclusively  destined  to  perform  the  function  of  sensation),  but 
gradually  implicating  the  nerves  of  motion  in  the  disease.  I  shall  now 
proceed  to  lay  before  you  the  details  of  this  case,  which  have  been 
noted  with  singular  accuracy  and  ability  by  the  gentleman  himself.  In 
a  letter  to  me  he  observes — 


i 


I 


GOUT.  46^ 

"  As  you  wish  for  a  description  in  writing  of  the  manner  in  wliich  I 
am  affected,  I  subjoin  every  particular  I  can  think  of  which  seems  likely 
to  throw  any  light  on  the  subject. 

*^  It  is  now  nearly  five  years  since  I  began  to  suffer  severely  from 
pains  in  my  limbs,  which  for  the  last  two  or  three  years  I  have  looked 
upon  as  neuralgia.  About  a  year  previous  to  that  time  I  had  occasional 
pains  in  one  foot,  which  increased  so  as  to  become  violent  on  one  occa- 
sion, after  a  long  ride.  I  had,  however,  been  always  in  the  habit  of 
riding,  and  considered  that  exercise  to  agree  particularly  well  with  my 
health.  Indeed,  I  had  found  hunting  of  great  use  to  me,  when  suf- 
fering from  liver  complaint,  having  had  inflammation  of  the  liver  twice 
in  my  life.  It  is  now  fourteen  years  since  I  had  the  last  attack  of  liver 
disease,  and  I  very  seldom  have  pain  in  my  side ;  whenever  it  occurs,  it . 
is  generally  removed  by  the  use  of  a  little  blue  pill. 

*'  When  first  the  pains  in  my  limbs  commenced,  they  were  confined 
to  my  feet ;  then,  for  a  long  time,  extended  no  higher  than  my  knees ; 
latterly  they  had  ascended  as  far  as  my  hips,  where,  and  in  the  groin,  I 
sometimes  experience  great  suffering.  I  have  had  occasional  twitches 
in  my  arms,  and  very  slightly  across  the  chest.  The  pain  always  comes 
on  with  sudden  violence,  which  renders  it  very  hard  to  bear,  especially 
when  it  attacks  me  during  sleep.  I  am  frequently  aware  of  its  ap- 
proach, from  a  general  feeling  of  discomfort  and  depression  :  from  which, 
in  the  beginning  of  my  complaint,  I  used  to  suffer  very  much  for  two 
or  three  days  before  an  attack.  These  paroxysms  have,  for  four  years, 
shown  a  great  tendency  to  periodicity,  recurring  generally  once  every 
week,  commencing  on  Saturday  or  Sunday,  and  sometimes  on  Triday, 
and  lasting  till  Monday.  They  have  twice  or  thrice  lasted  for  a  week 
together,  but  sometimes  continue  only  a  few  hours. 

In  the  commencement  I  have  occasionally  been  free  from  them  for 
two  or  three  months  together ;  and  within  the  last  year  was  free  from 
them,  at  two  different  periods,  for  a  whole  month.  When  in  pain,  I 
have  never  experienced  the  slightest  alleviation  from  any  thing,  except 
at  times  from  a  fuU  meal  with  wine,  particularly  champagne.  I  have 
often  been  unable  to  remain  in  bed,  from  the  violence  of  the  pain,  which 
is  increased  by  the  weight  of  the  bed-clothes,  or  the  slightest  touch  of 
any  thing ;  even  the  air  blowing  on  the  part  brings  on  violent  torture  : 
at  the  same  time  I  can  bear  strong  pressure,  or  even  a  blow  on  the 
parts,  without  making  me  worse.  The  pain  appears  to  be  quite  on  the 
surface,  except  that  sometimes  it  appears  deeply  seated,  particularly  in 
the  ankle-joint  and  shin  bone.  It  is  unaccompanied  by  any  redness  or 
swelling,  and  flies  instantaneously  from  one  limb  to  the  other,  rarely 
occurring  in  both  at  the  same  time.     It  leaves  behind  great  weakness 


470  CLINICAL    MEDICINE. 

of  the  affected  limb^  so  as  to  oblige  me  to  walk  with  a  stick  for  some 
time^  and  occasionally  with  two. 

"  One  very  unpleasant  consequence  of  the  pains  in  my  limbs  is,  that 
I  now  find  I  cannot  use  exercise  on  horseback,  if  I  leave  it  off  for  any 
time.  I  have  found  this  and  walking  at  all  times  conducive  to  my 
general  health.  Indeed  I  can  still  walk  a  good  deal,  even  during  an 
attack,  although  it  is  very  painful,  particularly  when  setting  out.  I 
find  it  necessary  almost  constantly  to  have  recourse  to  aperient  medi- 
cine— generally  rhubarb  pill.  At  times  I  have  had  giddiness  of  my 
head,  and  noise  in  my  ears,  to  a  very  distressing  degree ;  and  have  had 
recourse  to  powerful  purgatives,  and  even  bleeding,  to  remove  the 
symptoms,  without  effect.  A  medicine,  principally  nervous,  in  which 
gentian  was  an  ingredient,  relieved  me  at  one  time,  after  finding  the 
above  remedies  ineffectual. 

"  I  have  abeady  tried  iron,  mercury,  nitro-muriatic  acid,  stra- 
monium, arsenic,  and  the  external  use  of  croton  oil,  without  benefit, 
except  that  I  felt  rather  better  for  a  month  after  the  use  of  these  remedies, 
but  no  longer,  and  the  pain  returned  with  great  violence  at  the  end  of 
that  period.  The  counter-irritation  appeared  to  increase  my  sufferings. 
I  have  also  tried  anodyne  embrocations  without  effect.  Anxiety  of 
mind,  or  annoyance,  often  brings  on  an  attack.  I  even  remarked,  the 
other  day,  that  it  came  on  instantaneously,  on  breaking  a  tooth  whilst 
eating.  On  the  other  hand,  excitement,  whether  from  a  sudden  neces- 
sity for  exertion,  as  on  occasion  of  an  accident,  or  any  thing  that  gives 
a  pleasing  interest  and  occupation  to  my  mind,  such  as  travelling 
through  an  interesting  country,  seems  to  keep  off,  and  sometimes  even 
remove  an  attack.^' 

The  following  most  interesting  account  of  his  own  case  which  I  re- 
ceived from  Dr.  Mackness  of  Hastings,  and  which  I  read  from  his  letter, 
bears  much  similarity  to  the  foregoing  case ;  on  which  account  I  intro- 
duce it  here.  All  the  symptoms,  however,  may,  I  think,  be  ascribed  to 
functional  derangement  of  the  spinal  marrow : — 

"  The  symptoms  in  the  case  of  what  is  here  called  gouty  neuralgia 
are,  in  some  respects,  very  similar  to  what  I  have  myself  suffered,  and 
this  without  any  hereditary  or  constitutional  tendency  to  gout.  I  am 
inclined  to  think  that  the  malady  has  its  origin  in  slight  inflammation  or 
irritation  of  the  spinal  cord  or  its  membranes,  this  state  being  excited  by 
certain  impressions  made  upon  the  extremities  of  the  nerves,  especially 
of  the  lower  limbs,  and  carried  along  the  trunks  to  the  nervous  centres, — 
cold  being  usually  the  exciting  cause ;  but  for  this  to  produce  the  specific 
effect  of  which  I  speak,  I  beheve  it  necessary  that  the  digestive  organs 
should  be  in  a  state  of  irritation  :  such  was  the  case  with  me.     I  was 


GOUT.  471 

residing  in  the  country  at  the  earliest  commencement  of  my  disease, 
where  the  atmosphere  was  usually  loaded  with  moisture,  arising  from  a 
sluggishly  flowing  river,  a  short  distance  from  the  banks  of  which  my 
residence  stood.  I  had,  in  attending  to  my  professional  duties,  much 
night-work ;  riding,  perhaps,  for  several  miles  on  horseback  through  a 
foggy  atmosphere,  and  then  having  to  sit  for  hours  in  a  cold  cottage  or 
farm-house,  my  feet  and  legs  as  cold  as  if  they  were  immersed  in  ice 
water.  I  was  very  temperate  in  my  habits,  but  I  sufi'ered  much  from 
dyspepsia ;  at  first  the  pains  were  slight  and  the  paroxysms  very  short, 
but  gradually  they  became  more  severe  and  of  longer  continuance,  gener- 
ally affecting  the  lower  extremities ;  at  the  same  time  there  was  slight 
loss  of  power  in  these  limbs,  which  manifested  itself  by  a  little  awkward- 
ness of  gait,  and  was  more  observable  to  my  friends  than  to  myself.  This 
state  of  things  continued  rather  increasing  in  severity  for  two  or  three 
years,  at  the  end  of  which  period  my  gait  became  much  more  unsteady, 
and  I  found  it  diifi-cult  to  walk  in  the  dark,  or  where  my  eyes  were  not 
fixed  on  the  road.  Bilious  attacks  attended  with  constant  sickness  and 
vomitings  of  bile,  with  severe  pain  in  the  brow  and  shoulder,  then 
began  to  visit  me  at  stated  intervals,  these  intervals  becoming  shorter 
and  shorter,  until  I  rarely  passed  a  month  without  having  had  two  or 
three.  In  the  meantime  the  pain  became  more  severe ;  so  intense  was 
it  at  times,  that  I  have  as  much  dreaded  any  of  my  family  coming  within 
a  yard  or  two  of  me,  for  fear  that  some  part  of  their  dress  might  touch 
me,  and  thus  excite  a  paroxysm,  as  any  hydrophobic  patient  dreads  the 
sight  of  fluid  or  any  glistening  surface.  A  draught  of  air  was  often  quite 
sufficient  to  excite  the  paroxysm  :  what  was  perhaps  worse  to  bear  than 
even  the  pain  itself,  was  the  constant  dread  I  had  during  an  attack  of 
its  coming  on.  It  was  not  one  part  only  that  was  afi'ected,  but  often- 
times the  whole  of  the  extremities  in  turn,  yet  mostly  the  lower.  I 
have  sometimes  tried  to  point  out  to  my  friends  the  spots  which  the  pain 
attacked,  but  so  quick  were  the  transitions  from  one  place  to  another, 
that  although  I  have  tried  to  touch  each  part  successively,  I  have  always 
failed  in  being  able  to  do  so  sufficiently  quickly.  The  cutaneous  nerves 
were  often  so  sensitive,  that  the  slightest  touch  would  produce  the  most 
exquisite  torture  :  thus  giving  an  example  of  the  law  established  by  Dr. 
Marshall  Hall,  that  in  proportion  as  the  muscles  become  less  under  the 
control  of  the  will,  this  irritability  becomes  increased.  This  continued 
strain  upon  the  nervous  system  produced  epileptic  fits,  which  continued 
for  some  years,  and  another  affection  of  the  nervous  system — spasmodic 
closure  of  the  glottis,  began  at  this  time  to  show  itself,  often  threatening 
suffocation.  It  is  very  singular  that  my  father  was  subject  to  the  same 
affection.     At  length  I  gave  up  my  professional  duties,  after  having  suf- 


472  CLINICAL   MEDICINE. 

fered  for  four  years  a  martyrdom^  and  went  abroad,  at  first  with  some 
benefit,  but  I  afterwards  became  worse.  Having  been  accustomed  to  a 
very  active  life,  the  change  to  one  of  complete  idleness,  although  at  first 
useful  and  pleasant,  became  after  a  time  intolerable,  and  produced  a  state 
of  ennui  upon  the  mind  which  appeared  to  keep  up  the  malady.  In  tliis 
state,  weak  and  emaciated  as  I  was,  I  determined  once  more  to  resume 
my  professional  avocations,  and  as  I  had  found  by  experience  that  a  cold 
damp  atmosphere  with  a  clayey  subsoil  was  injurious  to  me,  I  chose 
this  place  for  a  residence,  where  I  have  now  resided  eight  years ;  my 
health  and  strength  gradually  improving.  The  means  which  I  have 
found  most  useful  in  my  case,  have  been  a  simple  but  nourishing  diet, 
taken  only  in  such  quantities  as  the  stomach  would  bear  without  a  feeling 
of  oppression,  moderate  exercise,  not  amounting  to  fatigue,  and  agreeable 
occupation  of  the  mind.  I  do  not  now  suffer  often  from  the  disease, 
and  when  I  do  suffer  the  attacks  are  trifling  compared  to  what  they  for- 
merly were.  My  firm  belief  is,  that  I  should  not  suffer  at  all  if  my  mind 
was  perfectly  quiet  and  pleasantly  occupied ;  but  I  have  now  a  large 
practice,  often  much  bodily  and  mental  fatigue,  and  sometimes  consider- 
able exposure  to  the  weather  in  long  journeys ;  and  as  these  are  insepar- 
able from  the  practice  of  a  profession  which  I  love  with  all  my  heart,  I 
make  up  my  mind  to  suffer  a  little  rather  than  forego  it.  I  have  reason 
to  think  that  the  situation  of  Hastings  is  peculiarly  favourable  to  my  dis- 
ease. I  have  never  fully  recovered  the  perfect  use  of  my  lower  extremities, 
yet  they  are  much  stronger  than  formerly ;  for  I  used  to  require  a  stick 
to  walk  with,  noAV  I  never  or  rarely  use  one.  I  do  not,  however,  walk 
much  as  I  find  I  am  soon  tired." 

Another  singular  affection  I  have  lately  witnessed  in  connexion  with 
gout,  I  may  mention  here.  A  lady  of  a  decidedly  gouty  habit,  aged 
sixty,  applied  to  me  under  the  following  circumstances  :  for  the  last  two 
months,  she  had  become  liable  to  a  daily  paroxysm,  which  observed  the 
following  course.  About  three  o'clock  in  the  afternoon,  her  nose  began 
to  grow  hot,  and  the  heat  continued  for  four  or  five  hours,  the  part  be- 
coming first  of  a  bright,  and  then  of  a  purplish  red  colour,  which  spread 
to  the  upper  portion  of  her  cheeks,  and  was  accompanied  by  some  un- 
easiness, but  no  pain,  and  always  subsided  about  the  same  hour  in  the 
evening.     I  advised  small  doses  of  colchicum  to  be  taken  in  this  case. 

In  general,  a  regular  attack  of  gout  in  the  extremities  is  preceded  by 
a  longer  or  shorter  period  of  constitutional  disturbance  and  dyspepsia. 
We  must  not,  however,  in  making  the  diagnosis  between  gout  and  rheu- 
matism, consider  tliis  distinction  as  not  liable  to  exceptions,  for  I  have 
seen  more  than  one  case  of  hereditary  gout,  in  which  the  arthritic  attacks 
came  on  suddenly,  without  the  slightest  precursory  derangement  of  the 


GOUT.  473 

health,  or  the  operation  of  any  assignable  cause.  I  have  as  yet  seen  no 
instance  of  a  similar  nature  in  acquired  gout. 

Another  exception  to  the  general  rule  is  also  worthy  of  notice.  In 
general,  a  fit  of  the  gout  is  preceded  and  accompanied  by  a  scanty  secre- 
tion of  turbid  high-coloured  urine.  As  the  fit  goes  off,  the  urine  increases 
in  quantity,  becomes  clearer  and  paler,  and  loses  its  tendency  to  deposit 
the  lithates  and  purp urates.  Now,  in  two  cases  of  hereditary  gout,  I 
have  seen  this  order  reversed,  and  the  approach  of  the  fit  announced  by 
a  great  increase  in  the  secretion  of  urine,  which  was  quite  watery  and 
limpid,  and  continued  so  until  the  violence  of  the  articular  inflammation 
began  to  dechne.  The  urine  then  became  scanty,  and  deposited  the 
lateritious  and  pink  sediment  in  great  abundance. 

That  the  gouty  diathesis  may  excite  its  specific  inflammation  in  most 
of  the  tissues  of  our  organs  is  a  fact  generally  admitted ;  but  I  regret  to 
state  that  our  knowledge  concerning  the  effects  which  it  produces  in 
these  various  tissues  is  far  from  being  accurate  or  extensive.  Beere, 
M'Kenzie,  Middlemore,  and  others,  have  done  much  towards  elucidating 
its  effects  on  the  eye  and  its  appendages ;  and  we  are  tolerably  well 
acquainted  with  its  progress  in  serous,  synovial,  and  fibrous  membranes. 
What  changes  it  produces  in  the  secretions  of  mucous  membranes,  is  a 
question  which  has  not  been  studied  with  an  attention  commensurate  to 
its  importance.  Thus,  though  all  acknowledge  the  existence  of  gouty 
cough  or  bronchitis,  the  diagnosis  and  history  of  this  affection  are  still 
very  incomplete.  This  has  been  acknowledged  by  Dr.  Stokes,  who  has 
published  by  far  the  best  account  of  bronchitis  which  has  yet  appeared.^ 
The  effects  of  gout  on  the  lining  membrane  of  the  urethra  and  bladder 
are  better  known  and  studied,  but  I  think  that  much  still  remains  to  bo 
done  in  this  as  in  every  other  class  of  inflammatory  diseases  where  the 
inflammation  depends  upon  a  constitutional  taint. 

In  my  published  lectures  I  have  long  since  expressed  an  opinion  at 
variance  with  that  generally  taught  concerning  the  bronchitis  and  pneu- 
monia w^iich  accompany  pulmonary  consumption,  and  I  have  brought 
forward  strong  reasons  for  believing  that  too  much  importance  has  been 
attached,  and  attention  too  exclusively  devoted,  to  the  tubercles  in  this 
disease.  Thus,  authors  talk  of  tubercular  pneumonia,  where  it  would 
be  more  correct  to  designate  the  affection  as  scrofulous  pneumonia  ac- 
companied by  tubercles ;  they  speak  of  tubercular  cavities  and  abscesses 
in  the  lung,  in  cases  where  scrofulous  cavities  and  abscesses  exist.  In 
fact,  I  repeat  it  emphatically,  that  the  essential  characteristics  of  phthisis 

•  "  On  the  Diagnosis  and  Treatment  of  Diseases  of  the  Chest,"  by  W.  Stokes,  M.D. 
This  work  places  its  author  among  the  first  medical  observers  of  the  day,  ^nd  has  ac- 
quired for  him  a  European  fame. 


474  CLINICAL   MEDICINE. 

pulmonalis  are  derived  from  scrofula.  This  it  is  which  converts  what 
would  be  common  into  consumptive  pneumonia  or  bronchitis — this  it  is 
which  so  often  renders  both  incurable. 

Tubercles  and  tubercular  infiltration  are  mere  results  of  nutrition 
morbidly  modified  by  scrofula ;  they  are  effects,  not  causes.  They  often 
exist  without  scrofulous  inflammation,  and  the  latter  may  exist  without 
them.  It  gives  me  much  pleasure  to  find  that  these  opinions,  which  I 
published  many  years  ago,  have  received  ample  confirmation  from  the 
observations  of  Dr.  Kingston,  in  a  paper  read  before  the  Eoyal  Medico- 
Chirurgical  Society  of  London,  and  shortly  noticed  in  the  Medical 
Gazette,  April  29,  1837. 

In  pursuing  the  subject  of  my  lecture,  I  shall  now  turn  to  the  con- 
sideration of  some  phenomena  connected  with  the  gouty  diathesis  which 
possess  a  much  deeper  interest,  and  lead  to  views  of  far  greater  im- 
portance. I  mentioned  before,  that  we  frequently  observe  flying  pains, 
or  twitches,  in  various  parts  of  the  body,  arising  from  a  rheumatic  or 
gouty  cause ;  that  in  some  instances  these  affections  appear  to  be  Hmited 
chiefly  to  the  nervous  trunks  or  branches,  and  that  we  have  thus  what 
may  be  termed  gouty  or  rheumatic  neuralgia.  We  are  familiar  with 
rheumatic  or  gouty  sciatica,  and.  we  know  that  the  history  and  termina- 
tion of  this  form  of  disease  often  prove  it  to  be  inflammation  of  a 
specific  character,  chiefly  confined  to  the  trunk  of  the  sciatic  nerve. 
Now,  it  is  not  unreasonable  to  suppose  that  this  specific  inflammation 
of  a  nervous  trunk  or  branch,  may,  like  other  inflammations,  extend 
farther,  so  as  to  involve  parts  of  more  importance  to  the  economy. 

What  I  wish  to  draw  your  attention  to  is  this — that  in  certain  cases, 
where  gout  attacks  the  nerves,  giving  rise  to  gouty  congestion  or  in- 
flammation, frequently  recurring,  and  acquiring  increased  strength  and 
deeper  root  as  it  proceeds,  the  morbid  affection  may,  after  years,  or 
even  months,  run  on  until  it  reach  the  spinal  cord,  involving  a  cer- 
tain portion  or  portions  of  that  organ,  and  producing  loss  of  sensation 
and  motion  commensurate  to  the  amount  of  spinal  derangement.  This 
is  by  no  means  an  anomalous  occurrence ;  it  is  merely  an  instance  of 
disease  originating  in  the  periphery  of  the  nervous  system,  passing 
along  the  trunk  of  the  aflected  nerve  with  a  retrograde  motion,  and 
finally  reaching  the  central  parts. 

It  is  too  much  the  custom  to  look  upon  paralysis  as  depending  upon 
original  disease  of  the  nervous  centres.  When  I  come  to  speak  of 
paralysis,  I  expect  to  be  able  to  prove  to  you  that,  very  often,  disease 
commencing  in  the  nerves  of  some  particular  part  or  organ,  may  be 
gradually  propagated  to  the  spine,  producing  all  the  symptoms  which 
are  referable  to  an  original  affection  of  the  nervous  centres.     I  shall 


I 


GOUT.  475 

also  bring  forward  numerous  facts  in  proof  of  the  propagation  of  dis- 
ease from  the  circumference  to  the  centre  of  the  nervous  system ;  and 
the  pathological  deductions  to  be  drawn  from  these  facts  seem  to  me  to 
include  all  the  physiological  discoveries  made  by  Miiller  and  Marshall 
Hall,  concerning  what  tlie  latter  terms  the  reflex  function  of  the  spinal 
marrow.  I  shall  be  able  to  show  you  that  enteritis,  arising  suddenly 
in  two  young  and  healthy  persons,  from  indigestion  and  obstruction 
caused  by  an  error  in  diet,  was  followed  in  both  by  well  marked  para- 
plegia. I  shall  likewise  bring  before  you  examples  of  paraplegia  con- 
nected with  stricture  of  the  urethra,  and  which  were  relieved  by  curing 
the  stricture ;  and  I  shall  detail  cases  of  acute  and  chronic  affections  of 
the  uterus  and  kidneys,  which  had  entailed  on  the  patients,  as  a  remote 
consequence  of  the  original  disease,  loss  of  the  power  of  motion  in  the 
lower  extremities,  sometimes  partial  and  curable,  sometimes  irreme- 
diable and  complete. 

The  cases  I  am  about  to  relate  to  you  now  are  most  interesting  and 
valuable,  and  enable  me  to  carry  this  principle  still  farther  by  proving 
that  gouty  inflammation  of  the  nerves  and  their  neurilemma,  may,  inpro-^ 
cess  of  time,  extend  to  the  spinal  marrow  and  its  investments,  and  give 
rise  to  derangements  of  the  latter,  term^inating  in  ramollissement  and 
structural  degeneration. 

The  subject  of  gouty  degeneration  of  the  spinal  cord  has  not  been 
alluded  to  distinctly  by  any  author  with  whom  I  am  acquainted,  and  is, 
as  far  as  I  can  learn,  quite  new.  The  deductions,  therefore,  which  are 
drawn  from  my  cases  must,  of  course,  be  subject  to  such  modifications 
as  may  be  derived  from  future  experience,  and  must  remain  to  be  con- 
firmed by  further  observation.  It  has  been  long  known  that  gout  may 
attack  the  brain,  and  the  existence  of  gouty  paraplegia  is  well  known  by 
practitioners  who  have  studied  attentively  the  progress  of  arthritic  af- 
fections. Thus,  in  a  case  which  I  witnessed  some  time  back,  in  con- 
sultation with  Mr.  Kirby,  he  prognosed  the  supervention  of  paraplegia 
at  a  time  when  the  indications  of  its  approach  could  not  have  been  dis- 
covered by  any  observer  of  less  experience  and  sagacity. 

I  have  already  stated  that  gouty  affections  of  the  brain  have  long 
been  known,  and  I  am  not  sure  that  some  of  the  older  authors  may 
not  have  alluded  to  gouty  affections  of  the  spinal  marrow ;  but  as  our 
knowledge  of  the  peculiar  state  of  the  brain  and  spinal  cord,  termed 
ramolhssement,  is  comparatively  recent,  and  not  dating  with  any  degree 
of  accuracy  earher  than  the  works  of  Abercrombie,  Rostan,  and  other 
modern  authors,  it  is  obvious  that  any  observations  made  by  the  older 
writers  concerning  gouty  affections  of  the  nervous  centres,  can  have  no 
distinct  reference  to  this  lesion.     The  connexion,  therefore,  of  ramol- 


476  CLINICAL    MEDICINE. 

lissement  of  tlie  spinal  cord  with  gout,  may  be  considered  now,  for  the 
first  time,  distinctly  pointed  out.  As  one  of  the  cases  which  I  am 
about  to  detail  presented  an  example  of  tlie  most  extensive  ramollisse- 
ment  of  the  spinal  marrow  on  record,  it  would,  on  this  account  alone, 
be  especially  deserving  of  attention ;  but  its  interest  is  increased  tenfold 
when  placed  in  juxta-position  with  the  second  case,  so  as  to  exhibit  in 
a  striking  point  of  view  the  close  resemblance  observable  in  the  march 
or  progress  of  both,  as  well  as  the  identity  of  the  lesion  discovered  after 
death. 

Mr. ,  residing  in  the  Island  of  Anglesey,  was  very  much  addicted 

to  field  sports,  and,  while  thus  engaged,  would  occasionally  remain  for 
a  whole  day  without  food.  He  was  also  very  fond  of  angling,  and  has 
been  frequently  known  to  wade  up  to  his  waist  in  water  for  many  hours 
together,  during  very  cold  weather.  His  general  health  was  good,  and 
his  habits  were  abstemious.  In  1825,  when  about  twenty-five  years  of 
age,  he  had  fever,  attended  with  inflammation  of  the  joints,  and  said 
to  be  rheumatic :  some  pain  and  stifi'ness,  and  an  evident  enlargement 
of  the  knee-joints,  remained  after  the  other  articular  affections  had 
disappeared ;  these  symptoms,  however,  yielded  in  a  few  months  to  rest 
and  appropriate  treatment.  His  health  also  improved  greatly,  and  he 
had  no  complaint  of  any  kind  whatever  until  the  autumn  of  1828,  when 
he  had  a  slight  attack  of  ordinary  cholera,  after  returning  from  a  shoot- 
ing excursion. 

In  the  spring  of  1832,  he  was  attacked  with  pain  in  one  foot,  sup- 
posed to  be  of  a  gouty  nature.  This  pain  disappeared  during  a  drive 
of  fifteen  miles  in  an  open  carriage,  but  a  certain  degree  of  tenderness 
remained,  and  was  always  felt,  more  or  less,  in  the  part  originally 
affected.  He  had  a  similar  attack  of  pain  and  tenderness  in  the  same 
foot  in  the  following  autumn.  At  the  time  when  this  attack  com- 
menced he  was  twenty  miles  from  home,  and  observed  that  during  his 
journey  the  pain  became  diminished  as  before,  and  in  a  few  days  sub- 
sided altogether.  In  August,  1833,  he  had  a  similar,  but  much  more 
severe  attack  :  the  pain  was  much  more  violent  than  before,  and  both 
feet  were  affected.  This,  however,  did  not  prevent  him  from  following 
field  sports  as  usual.  He  went  on  horseback  to  the  mountains  to 
shoot  grouse ;  and  to  this  exercise,  and  drinking  a  bottle  of  wine,  he 
attributed  his  speedy,  or  rather  sudden,  recovery  from  the  pain  in  his 
feet. 

Hitherto  we  have  seen  a  naturally  strong  constitution  struggling  suc- 
cessfully against  exposure  to  cold,  imprudent  habits,  and  a  most  inju- 
dicious method  of  disturbing,  or  rather  repelling,  local  inflammation 
depending  on  a  gouty  diathesis.     It  is  not  easy  to  explain  how  it  hap- 


GOUT.  477 

pened  that  driving  in  an  open  carriage,  or  riding  over  the  mountains, 
so  effectually  cut  short  the  paroxysms  of  gout  in  the  feet ;  but  it  is 
enough  to  know  that  the  fits  were  suddenly  and  imprudently  arrested,  to 
be  prepared  for  the  consequences  which  ensued — viz.,  an  irregular  dis- 
tribution of  the  gouty  effort,  and  its  determination  to  internal  organs. 

In  September,  1 833 — that  is,  about  a  month  after  the  sudden  sub- 
sidence of  the  last  attack — he  was  seized  with  violent  colic,  accom- 
panied by  obstinate  constipation.  The  pain  was  very  severe,  but  he 
suffered  more  from  a  general  feeling  of  restlessness  (a  restlessness  be- 
yond behef,  as  he  expressed  it)  than  from  actual  pain.  He  was  also 
greatly  annoyed  by  singultus,  and  was  jaundiced  after  recovering  from 
the  attack  of  cohc.  In  January,  1834,  he  had  another  attack  of  colic, 
preceded  by  a  fit,  the  precise  nature  of  which  I  was  unable  to  ascertain. 
As  these  abdominal  attacks  frequently  recurred,  I  shaU  give  a  description 
of  one  of  them,  as  communicated  to  me  by  Dr.  Llewelyn  Jones,  jun., 
his  attending  physician. 

"A  dull,  wearing,  and  fixed  pain  would  attack  the  patient  in  the 
region  of  the  colon  :  this  pain  was  not  increased  by  pressure,  and  was 
accompanied  by  nausea,  occasionally  by  vomiting,  and  always  by  ob- 
stinate constipation.  These  symptoms  were  attended  with  a  most  dis- 
tressing sensation  of  restlessness  and  anxiety.  They  lasted  on  one 
occasion  for  three  days  and  nights  before  I  could  get  the  bowels  opened, 
when  they  were  immediately  mitigated.  The  pulse  was  never  quickened, 
and  in  general  remained  natural ;  but  if  the  attack  was  prolonged,  it 
became  weak.  There  never  was  any  fever,  nor  any  well-marked  indica- 
tion of  inflammation  in  the  abdomen.  These  attacks  were  always  pre- 
ceded or  followed  by  a  gouty  affection  of  the  feet."*' 

The  attacks  in  the  stomach  and  bowels  recurred  frequently,  and 
always  with  the  same  symptoms,  until  August,  1835,  when  a  visible 
tremor  of  the  fingers  became  observable :  during  some  preceding  attacks 
he  used  to  complain  of  weakness  of  the  wrists  and  pains  in  the  fingers, 
particularly  the  last  joints.  As  the  disease  progressed,  these  pains  be- 
came more  intense  and  extensive,  and  the  torture  he  felt  in  the  hands 
and  arms  was  beyond  description.  After  August,  1835,  he  began  to  lose 
the  use  of  his  arms,  the  tremors  increased,  and  he  began  to  complain 
of  stiffness  about  the  neck,  with  great  restlessness  and  anxiety.  The 
abdominal  attacks  came  on  occasionally,  but  not  so  severely  as  before. 
The  arms  became  gradually  weaker,  until  the  loss  of  muscular  power 
was  complete,  and  they  were  greatly  emaciated ;  but  Dr.  Jones,  who 
had  the  patient  under  his  observation  until  August,  1836,  could 
not  detect  any  evident  diminution,  either  in  the  upper  or  lower  extre- 
mities, and  the  intellectual  faculties  remained  perfectly  unimpaired. 


478  CLINICAL   MEDICINE. 

In  October,  1835,  two  months  after  the  state  of  the  upper  extre- 
mities had  indicated  the  approach  of  paralysis,  the  lower  extremities 
became  similarly  engaged ;  they  were  affected  with  tremors  and  weak- 
ness, and  in  the  following  December  the  patient  had  an  attack  of  violent 
pain,  with  swelling  and  increased  heat  in  the  ball  of  one  foot,  which 
was  pronounced  to  be  of  a  distinctly  gouty  character.  After  each 
attack  of  pain  in  the  feet,  as  I  have  been  informed  by  this  gentleman's 
sister,  the  loss  of  power  in  all  his  limbs  increased,  and  if  he  gained  a 
little  strength  in  the  intervals  between  these  attacks,  a  recurrence  of  the 
paroxysms  always  made  him  worse  than  before. 

In  February,  1836,  I  went  to  Anglesey  to  visit  this  gentleman,  and 
saw  him  in  consultation  with  Dr.  Jones  and  Dr.  Wilhams,  of  Denbigh. 
After  a  minute  examination  of  the  history  and  symptoms  of  the  case, 
I  declared  it  to  be  my  opinion  that  a  gouty  inflammation  had  attacked 
the  nerves  of  the  extremities,  and  had  finally  extended  to  the  spinal 
cord  and  its  sheath.  I  said,  that  at  an  earlier  period  of  the  disease  I 
would  have  advised  salivation  by  mercury,  but  as  that  was  inadmissible 
under  the  existing  circumstances,  we  should  have  recourse  to  other 
measures.  I  forgot  to  state,  that  from  the  commencement  of  the  dis- 
ease, the  advice  of  Sir  B.  Brodie,  and  other  eminent  practitioners  in 
London  had  been  obtained  by  letter. 

It  would  be  useless  to  detail  the  various  general  and  local  remedies 
fruitlessly  employed  in  this  gentleman's  case.  He  went  to  Liverpool 
in  August,  1836,  for  the  benefit  of  further  advice ;  but  finding  no  rehef, 
returned  to  Denbigh,  where  he  died  in  the  ensuing  October.  Tor  some 
time  before  his  death  he  was  greatly  emaciated,  and  quite  paralytic  in 
all  his  limbs,  but  retained  his  faculties  to  the  last.  His  body  was  exa- 
mined by  Dr.  "Williams,  whom  I  had  met  in  consultation  in  the  pre- 
ceding February.  This  gentleman  informed  me,  that  the  viscera  of  the 
thorax  and  abdomen  were  healthy  and  normal,  that  no  derangement  or 
lesion  of  the  brain  could  be  detected,  but  that  the  spinal  cord,  opposite 
to  the  last  cervical  and  first  dorsal  vertebrae,  was  softened  to  the  consis- 
tence of  thick  cream  •  the  remainder  of  the  cord  was  also  softer  than 
natural,  but  did  not  present  any  thing  pecuhar  in  other  respects. 

In  a  letter  which  I  have  since  received  from  Mr.  Williams,  to  whose 
kindness  I  am  much  indebted,  he  expresses  himself  with  regard  to  the 
nature  of  the  patient's  disease,  in  a  way  which  confirms  the  views  I  have 

taken.     He  observes — "  I  once  saw  Mr. in  an  attack  of  the  gout 

in  the  feet,  about  three  years  before  his  death.  There  was  much  pain, 
and  a  decided  gouty  blush.  Exposure  in  fishing  and  shooting  to  a 
very  imprudent  degree,  while  under  the  influence  of  these  gouty  attacks, 
I  have  no  doubt  did  much  to  render  the  disease  irregular  and  erratic." 


GOUT.  479 

The  fact  that  the  tremors  and  loss  of  power  commenced  in  the  arms 
two  months  before  indications  of  paralysis  of  the  lower  extremities  ap- 
peared, is  sufficient  evidence  to  prove  that  the  spinal  marrow  was  not 
the  point  from  which  the  diseased  action  proceeded  originally ;  for  had 
this  been  the  case,  an  affection  of  this  organ,  sufficiently  violent  to  give 
rise  to  paralysis  of  the  upper  extremities  so  gradual  in  its  progress, 
and  so  well  developed,  must  long  before  this  period  have  occasioned 
paralysis  of  the  legs  also.  There  is  a  striking  analogy  between  the  pro- 
gress of  the  tremors  and  paralytic  symptoms  in  tliis  case  and  in  cases  of 
painter^s  colic ;  and  the  analogy  likewise  holds  good  as  to  the  violent 
spasmodic  affection  of  the  bowels,  and  the  constipation  observed  in 
both.  It  is  further  worthy  of  notice,  that  in  painter^s  colic  the  nervous 
affection  is  accompanied  by  pain  and  weakness  of  the  extremities,  and 
ultimately,  although  long  after  the  commencement  of  the  disease,  by 
spinal  tenderness, — a  fact  which  has  been  already  noticed  by  Dr.  Bright. 
Again,  in  painter^s  colic,  as  in  the  disease  which  I  have  just  detailed, 
the  affection  of  the  spinal  cord,  and  the  consequent  paralysis,  are 
evidently  subsequent  to  the  disease  of  the  peripheral  portion  of  the 
nerves. 

The  next  case,  which  I  shall  now  proceed  to  detail  is  one  of  equal 
interest  and  importance.  A  gentleman  of  robust  frame,  aged  about 
fifty-five,  and  having  an  hereditary  predisposition  to  gout,  to  which  his 
father  had  been  a  martyr,  and  which  had  exhibited  itself  in  one  of  his 
sons  at  the  early  age  of  thirteen,  consulted  me  on  the  the  7  th  of  June, 
1836.  Being  a  man  of  extensive  landed  property,  he  resided  chiefly  in 
the  country,  and  was  in  the  habit  of  using  much  active  employment  and 
exercise,  but  indulged  rather  freely  in  the  pleasures  of  the  table.  After 
suffering  much  annoyance  from  dyspeptic  attacks,  and  various  premoni- 
tory symptoms,  he  had  a  regular  paroxysm  of  gout  in  the  spring  of  1828 ; 
he  had  a  similar  one  in  1830,  and  another  in  1832,  each  occurring,  as 
before,  during  the  spring  season,  and  remarkably  severe.  During  the 
year  1832,  he  had  several  slight  returns  of  the  complaint,  and  in  January, 
1833,  had  an  alarming  attack  of  an  enteritic  character,  accompanied  by 
spasms  of  the  stomach  and  acute  pain  of  the  extremities.  In  the  autumn 
of  1834  he  suffered  greatly  from  a  nephritic  affection,  and  got  relief  after 
passing  a  considerable  quantity  of  uric  acid  gravel. 

In  the  spring  of  1835  he  had  a  fall  from  his  horse,  and  for  some  time 
afterwards  complained  of  pain  in  the  small  of  the  back  and  around  the 
trunk.  He  recovered,  however,  and  during  the  summer  and  autumn  of 
that  year  remained  pretty  well ;  but  in  the  last  week  of  December  caught 
cold,  which  was  followed  by  severe  cough,  and  pains  in  the  chest  and 
feet :  the  latter  were  then  considered  to  be  the  effects  of  gout.     From 


480  CLINICAL   MEDICINE. 

this  period,  his  health,  though  often  apparently  restored,  was  never  firm  : 
he  became  subject  to  sudden  attacks  of  pain,  particularly  in  the  chest, 
which  gave  liim  much  uneasiness.  On  the  3d  of  June  he  consulted  a 
physician  in  his  neighbourhood,  to  wnom  he  described  his  ailment  as  "  a 
shght  pain  in  the  right  side,  which  troubled  him  only  a  short  time  before 
he  got  up  in  the  morning ;"  this  he  stated  he  had  felt  occasionally  for 
two  months  before.  A  very  careful  examination  was  made  over  the 
situation  of  the  liver,  the  place  in  which  he  said  he  felt  pain,  but  no 
tenderness  or  swelling  whatever  was  detected,  nor  was  there  any  in  the 
direction  of  the  spinal  cord.  His  pulse  was  at  this  time  perfectly  re- 
gular, his  bowels  natural,  and  no  dyspeptic  symptoms  existed.  He  used, 
by  the  advice  of  this  physician,  tonic  and  laxative  pills,  and  a  stimulant 
embrocation. 

When  he  consulted  me  on  the  7th  of  June,  1836,  I  found  him 
labouring  under  what  appeared  to  me  to  be  pleurodynia  of  an  inter- 
mittent and  gouty  character.  During  the  day  he  was  perfectly  free 
from  pain,  but  in  the  evening  the  pain  commenced,  and  continued  with 
violence  until  morning.  It  is  unnecessary  to  detail  here  the  various 
local  and  constitutional  remedies  which  I  employed  in  this  gentleman's 
case,  but  without  any  favourable  result.  Erom  the  middle  of  June  his 
symptoms  became  worse ;  during  the  first  part  of  the  night  his  pains 
very  severe ;  towards  morning  he  usually  obtained  relief  by  lying  on  his 
face,  and  carefully  avoiding  all  motion.  About  the  latter  end  of  July,  the 
pain,  which  had  been  almost  constantly  felt  at  the  right  side,  moved  to 
the  left,  imparting  at  one  time  the  feeling  as  if  a  spear  were  passing 
through  the  diaphragm,  and  at  another  resembling  the  sensation  as  if 
these  parts  were  squeezed  in  a  vice.  When  he  was  in  the  horizontal 
position  this  pain  was  accompanied  by  a  sense  of  weight ;  and  at  times 
the  pain  would  shoot  upwards  to  the  clavicles,  producing  tenderness  of 
the  intercostal  spaces.  When  the  diaphragm  was  free  from  pain,  it 
most  commonly  attacked  the  postero-inferior  edges  of  the  scapula,  and 
the  dorsal  region  in  its  vicinity. 

In  August  he  tried  the  use  of  the  warm  bath,  and  found  temporary 
relief  from  the  first  he  took ;  he  remained  too  long  in  the  second,  which 
was  heated  to  the  temperature  of  100,  and  nearly  fainted.  He  used  the 
warm  bath  six  or  eight  times,  but  found  no  material  benefit  from  it,  and 
could  not  bear  the  pain  produced  by  the  jolting  of  his  carriage  in  going 
thither.  About  this  time  there  was  a  visible  alteration  in  his  gait  and 
figure ;  the  left  shoulder  was  elevated,  his  whole  frame  atteimated,  and 
his  face  pale ;  he  had  nearly  lost  all  power  of  bending  the  spine,  and 
walked  with  a  peculiar  stiffness  of  gait  as  if  his  arms  were  pinioned.  On 
the  morning  of  the  21st  of  August  he  stated  that  he  had  sufi'ered  great 


GOUT.  4'Sl 

agouy  (luring  the  night,  and  on  its  abating,  considerable  tumefaction 
was  observable  under  the  right  ribs.  Dyspeptic  symptoms  now  became 
lu-gent;  his  urine  scanty  and  turbid ;  he  became  melancholy,  and  his 
mind  was  wholly  occupied  with  sad  presentiments.  At  my  recommen- 
dation he  came  to  town,  in  order  to  place  himself  under  my  more  imme- 
diate observation,  and  to  have  the  benefit  of  a  consultation. 

About  the  30th  of  August  he  got,  to  his  great  joy,  an  attack  of  gout  in 
both  feet ;  while  this  lasted  which  was  for  about  six  days,  he  had  complete 
relief  from  the  agonizing  pains  in  the  diaphragm  and  chest.  The  interval 
of  tranquillity  was  however,  but  of  brief  duration ;  tlie  inflammatory  affec- 
tion of  the  feet  suddenly  subsided,  and  the  pain  attacked  the  diaphragm 
with  increased  intensity.  His  strength,  which  had  been  rapidly  failing, 
now  gave  way,  and  he  became  quite  paraplegic.  About  the  10th  of 
September  the  abdomen  became  engaged,  without  any  alleviation  of  the 
thoracic  symptoms,  and  he  began  to  complain  of  constipation,  tympanitis, 
and  abdominal  tenderness.  The  mucous  membrane  of  the  bladder 
became  next  affected ;  he  had  retention  of  urine,  with  great  irritation  of 
the  prostate  gland,  and  it  was  necessary  to  draw  off  the  water  with  the 
catheter  several  times  in  the  day.  This  state  continued  from  the  2 2d 
of  September  to  the  10  th  of  November,  when  the  sphincter  of  the 
bladder  became  paralysed,  and  the  urine  drained  off  as  fast  as  it  was 
secreted. 

During  all  this  time  the  urine  continued  to  present  the  characteristic 
marks  of  the  lithic  acid  diathesis  in  an  extreme  degree,  and  contrasted 
strongly  with  the  secretion,  furnished  by  the  inflamed  mucous  mem- 
brane of  the  bladder,  which  consisted  of  a  greyish  or  whitish  yellow, 
viscid,  and  somewhat  puriform  mucus,  containing  either  a  free  alkali, 
or  an  alkaline  carbonate.  This  secretion  was  extremely  adhesive,  and 
hung  down  in  long  ropy  filaments  when  the  vessel  in  which  it  stood  was 
inverted.  The  nature  of  this  mucus  was  such  as  to  prevent  any  re- 
action from  taking  place  between  its  own  alkali  and  the  acid  of  the 
urine.  The  coexistence  of  two  secretions  in  the  bladder,  the  one 
alkaline  and  the  other  acid,  as  observed  in  this  case,  is  extremely 
curious. 

In  this  way  the  patient's  sufferings  went  on  every  day  increasing,  and 
requiring  the  most  extraordinary  care  to  produce  any  alleviation,  a  task* 
which  was  discharged  with  the  most  indefatigable  humanity  and  atten- 
tion by  Mr.  Richardson,  to  whom  I  am  indebted  for  most  of  the  details 
connected  with  the  earlier  history  of  this  case.  About  ten  days  before 
his  death,  the  extremities,  upper  as  well  as  lower,  and  the  trunk,  became 
quite  paralytic ;  and  from  the  cervical  vertebrae  downwards,  all  power 
of  motion  and  sensation  was  lost.     His  voice  now  became  weak  and  in- 

VOL.   I.  31 


482  CLINICAL   MEDICINE. 

articulate^  deglutition  was  greatly  impeded,  and  he  finally  sank  on  the 
27th  of  November,  1836. 

It  may  be  necessary  to  state,  that  at  the  time  the  paraplegia  was 
beginning  to  seize  on  the  extremities,  the  patient  was  much  annoyed  by 
occasional  involuntary  jerkings  of  the  weakened  limbs.  This  morbid 
action  of  the  voluntary  muscles  continued  when  all  power  of  voluntary 
motion  had  completely  ceased. 

This  gentleman's  body  was  examined  twenty  hours  after  death,  by 
Mr.  Adams.  The  body  and  limbs  were  greatly  emaciated,  and  there 
were  several  sloughing  sores  on  various  parts  of  the  body  and  limbs, 
particularly  over  the  scapulae,  sacrum,  and  ilium.  The  brain  was  per- 
fectly healthy,  with  the  exception  of  a  slight  effusion  under  the  arach- 
noid, and  into  the  fourth  ventricle.  On  opening  the  spinal  canal,  which 
was  done  with  extraordinary  care  and  accuracy,  the  spinal  marrow,  from 
the  fourth  cervical  vertebra  down  to  its  dorsal  termination,  was  found 
converted  into  a  morbid  mass,  of  an  ash-grey  colour  and  pulpy  consis- 
tence. The  theca  was  quite  healthy ;  but  on  the  first  transverse  sec- 
tion of  it  a  great  quantity  of  yellow  serum  flowed  out,  emptying  at  the 
same  time  the  fluid  contained  in  the  fourth  ventricle  of  the  brain.  When 
the  medulla  spinalis  was  slit  from  above  downwards,  various  shades  of 
colour  were  noticed  on  the  surfaces  of  the  sections.  Opposite  to  the 
third  dorsal  vertebra  a  blackish  colour  prevailed ;  and  from  this  down- 
wards a  yellowish  hue  was  noticed.  Two  little  tumors,  about  the  size 
of  filberts,  were  found  attached  to  the  crura  of  the  fourth  dorsal  ver- 
tebra; these,  as  Mr.  Adams  remarked,  were  in  all  probability  merely 
accidental  formations.  The  bladder  was  very  much  thickened  in  aU  its 
coats,  and  was  so  contracted  that  it  could  not  contain  more  than  three 
ounces ;  its  internal  surface  was  of  a  dark  green  colour  approaching  to 
black.  The  ureters  were  also  thickened,  the  kidneys  enlarged,  and 
their  lining  membrane  of  the  same  dark  colour  as  the  bladder.  The 
pelves  and  infundibula  of  the  kidneys  were  dilated,  and  contained  a 
reddish  diseased  urine,  with  some  puriform  matter,  the  odour  of  which 
resembled  that  of  the  urine  passed  during  the  three  weeks  previous 
to  his  death.  The  other  viscera  did  not  present  any  thing  worthy  of 
remark. 

In  order  to  understand  the  nature  and  progress  of  a  disease  like  this, 
which  travelled  in  a  retrograde  direction  along  the  nerves  and  their 
sheaths  to  the  spinal  marrow,  it  may  be  well  to  point  out  some  of  the 
more  striking  phenomena  by  which  it  was  characterized.  In  the  first 
place,  the  long  continuance  of  the  pains  at  one  side  of  the  body  only, 
is  in  itself  a  demonstration  that  the  disease  was  then  situated  in  the 
peripheral  extremities  of  the  nerves,  and  not  in  the  spinal  marrow,  for 


GOUT.  483 

it  has  been  well  observed  by  Ollivier,  that  inflammation  of  the  spinal 
marrow  or  its  sheath  can  never  remain  confined  to  one-half  of  either 
for  more  than  a  very  limited  period.  Indeed,  so  narrow  is  the  cavity 
in  which  these  parts  are  contained,  and  so  intimate  is  the  connexion  of 
their  constituent  parts,  that  it  is  quite  impossible  for  inflammation  to 
remain  more  than  a  few  hours,  or  at  most  a  day  or  two,  confined  to 
either  side. 

Some  facts  connected  with  disease  of  the  spinal  vertebrse,  and  the 
pains  accompanying  the  progress  of  that  disease,  may  appear  to  contra- 
dict this  view  of  the  subject ;  for  in  vertebral  caries  pains  are  often  felt 
at  one  side,  -or  in  one  limb — ^nay,  they  often  cease,  or  seem  intermittent. 
Now  in  order  to  explain  this  we  have  only  to  recollect  that  here  the 
inflammation  does  not  commence  in  the  spinal  marrow  or  theca,  but  in 
the  bones,  and  that  the  nerves,  after  their  exit  from  the  spinal  cord, 
are  affected  in  all  cases  before  the  cord  itself.  The  reason  is  obvious ; 
the  afiection  of  the  nerves  is  secondary,  and  solely  derived  from  their 
proximity  to  the  inflamed  bone  and  investing  tissues ;  and  consequently 
the  nerves  on  one  side  may  be  affected,  while  the  corresponding  nerves 
on  the  other  side  escape  for  the  time,  and  until  the  disease  in  the  bone 
extends  itself  to  their  neighbourhood  also.  This  view  of  the  subject 
has  not  escaped  the  notice  of  German  pathologists. 

In  the  case  above  related  the  pains  continued  in  one  side  for  months, 
and  were  then  suddenly  transferred  to  the  other,  an  occurrence  which  is 
quite  irreconcilable  with  the  idea  of  their  dependence  on  primary  spinal 
disease.  The  well-marked  ease  the  patient  experienced  when  the  gout 
appeared  in  the  feet,  and  the  perfect  intermissions  of  pain  which  he 
frequently  enjoyed  during  the  earlier  stages  of  the  complaint,  afford 
strong  evidence  that  the  pains,  however  violent  and  excruciating  they 
might  have  been  during  the  paroxysms,  did  not  depend  on  an  original 
affection  of  the  spinal  cord.  Had  the  fall  which  this  gentleman  received, 
or  any  other  injury,  induced  inflammation  of  the  spinal  cord,  and  sub- 
sequent degeneration  of  structure,  the  order  and  course  of  his  symptoms 
would  have  been  very  different,  and  long  intervals  of  comparative  ease 
would  not  have  intervened  between  the  appearance  of  the  first  pains  and 
the  subsequent  paralysis. 

When  paraplegia  originates  in  disease  of  the  spinal  cord  itself,  reten- 
tion of  urine,  or  irritability  of  the  bladder,  often  announce  the  approach 
of  the  disease  long  before  the  loss  of  power  in  the  limbs  becomes  evi- 
dent ;  whereas,  in  all  those  cases  in  which  the  paralysis  creeps  from  the 
extremities  along  the  nerves  towards  the  spinal  marrow,  the  bladder  is 
affected  only  at  a  late  period  of  the  disease,  as  occurred  in  the  case 
which  I  have  just  detailed.     Finally,  the  remarkable  similarity  which 


484  CLINICAL   MEDICINE. 

exists,  in  various  points,  between  this  case  and  that  of  the  Welsh  gen- 
tleman, who  had  never  met  with  any  accident  or  injury,  and  in  whom 
a  considerable  degree  of  ramollissement  was  observed,  leaves  no  doubt 
that  in  both  instances  the  disease  commenced  with  gouty  neuralgia,  and 
inflammation  of  the  nervous  extremities  and  their  sheaths,  which  gradu- 
ally extended  to  the  central  portions  of  the  nervous  system,  and  ulti- 
mately involved  the  spinal  cord. 

It  is  of  great  importance  that  you  should  be  aware  of  this  termination, 
and  know  that  in  gouty  habits  the  sad  results  already  noticed  may  be 
produced  :  particularly  as  a  knowledge  of  this  fact  may  lead  to  the  timely 
adoption  of  preventive  measures.  Having  experienced  the  total  inefficacy 
of  colchicum,  hydriodate  of  potash,  strychnia,  and  all  the  usual  reme- 
dies, in  relieving  or  removing  this  form  of  disease,  I  would  be  strongly 
inclined  to  recommend  the  early  insertion  of  issues  over  the  spine,  with 
prompt  and  decided  mercuriahzation.  The  late  Mr.  CoUes  has  recom- 
mended the  use  of  mercury  in  paraplegia,  and  cites  some  cases  in  sup- 
port of  the  utility  of  the  practice.  It  is  to  be  regretted  that  he  has  not 
given  any  hints  as  to  the  mode  of  diagnosing  the  cases  likely  to  be  be- 
nefitted by  the  mercurial  treatment,  from  those  in  which  mercury  would 
be  inadmissible.  Hence  his  recommendation  loses  much  of  its  value, 
and  cannot  serve  as  a  guide  to  those  who  have  to  treat  spinal  disease 
connected  with  paralytic  symptoms.  It  appears,  however,  sufliciently 
plain,  that  mercury,  employed  at  an  early  period  of  the  disease,  is  most 
likely  to  prove  serviceable  where  symptoms  of  paralysis  arise  from  in- 
flammatory affections  of  the  nerves  or  their  neurilema,  or  of  the  spinal 
cord  and  its  sheath. 

So  far  at  present  on  the  subject  of  paralysis,  as  connected  with  the 
gouty  diathesis.  I  hope  to  be  able,  in  a  short  time,  to  bring  it  again 
before  you  in  a  more  complete  and  extended  form. 

In  the  preceding  observations  we  proved  that  gout  often  attacks  the 
nerves  of  the  extremities  in  the  first  instance,  and  then  pursues  a  retro- 
grade course  until  it  reaches  the  spinal  marrow.  It  is  an  acknowledged 
character  of  gout  that  it  wanders  from  one  organ  to  another,  and  that  it 
is  very  uncertain  as  to  the  periods  and  duration  of  its  attacks,  sometimes 
appearing  to  have  ceased  altogether,  again  only  to  return  with  redoubled 
violence.  These  characters  of  gout  are  strikingly  displayed  in  the  two 
cases  I  have  related,  where  it  finally  seized  on  the  spinal  marrow ;  and 
it  is  quite  possible  that  what  took  place  towards  the  fatal  terminations 
of  these  cases,  may  in  other  gouty  subjects  occur  at  a  much  earlier 
period,  and  without  the  previous  occupation  by  the  disease  of  the 
nerves  of  the  extremities  :  indeed,  there  is  no  reason  why  gout  should 
not  attack  the  spinal  marrow  and  its  investing  membranes  in  the  first 


GOUT.  485 

instance,  or  in  consequence  of  metastasis.  That  rheumatism,  the  dis- 
ease most  closely  allied  to  gout,  may  do  so,  has  been  proved  by  nume- 
rous examples,  of  which  we  owe  some  of  the  most  striking  to  Dr.  Cop- 
land and  Dr.  Prichard,  for  the  result  of  w^hose  researches  on  this  sub- 
ject I  must  refer  you  to  the  article  Chorea,  in  Copland's  Dictionary  of 
Practical  Medicine,  where  you  will  find  that  rheumatism  not  unfrequently 
produces  both  acute  and  chronic  inflammation  of  the  spinal  membranes. 
These  observations  I  make  with  the  intention  of  proving  that  my  views 
concerning  gouty  affections  of  the  spinal  cord  are  borne  out  by  analogy, 
and  the  experience  of  others  with  respect  to  rheumatism. 


486 


LECTURE  XXXII. 


EHEUMATISM. SCIATICA    AND    LUMBAGO. 


I  SHALL  commence  to-da/s  lecture,  gentlemen,  with  a  few  obser- 
vations on  that  rheumatic  affection  of  the  joints,  to  which  I  shall  give 
the  name  of  arthritic  rheumatism.  You  will  meet,  in  practice,  with 
cases  of  arthritic  rheumatism,  attended  with  fever,  where,  after  the  violent 
inflammatory  symptoms  have  subsided,  the  arthritic  inflammation  will 
continue  to  wander  from  joint  to  joint,  sometimes  almost  entirely  vanish- 
ing, and  then  again  re-appearing.  You  entertain  hopes  of  getting  your 
patient  over  the  disease,  and  he  is  indeed  better;  but,  on  your  next  visit, 
you  find  that  the  pain  has  fixed  itself — suppose  in  the  wrist  joint.  If 
such  a  pain  as  this  should  appear  while  the  acute  symptoms  are  present, 
besides  the  general  remedies,  you  wiU  employ  local  means  of  relief; 
and  some  persons,  as  for  instance.  Dr.  Elliotson,  would  make  cold  appli- 
cations to  the  part :  but  this  I  do  not  approve  of,  nor  would  I  recom- 
mend you  to  practise  it.  However,  generally  speaking,  your  treatment 
consists  in  leeching  the  affected  part,  the  internal  exhibition  of  col- 
chicum,  &c. 

What  I  would  urge  on  your  attention  is,  can  you  trust  to  leeches  on 
all  occasions,  and  at  every  period  of  the  disease  ?  No ;  there  is  a 
period  when  you  must  blister ;  there  is  a  time  when  stimulant  and  tonic 
applications  become  indispensable.  The  general  treatment  of  every  case 
of  arthritis  must  close  with  tonics.  Eirst,  you  pursue  the  antiphlogistic 
treatment,  next  you  employ  specific  remedies,  and  lastly,  you  have 
recourse  to  tonics ;  and  so  likewise  with  the  local  applications.  In  the 
beginning,  local  pain,  tenderness,  and  swelling,  depend  on  active  inflam- 
mation, and  yield  most  readily  to  leeching.  As  the  disease  advances, 
the  number  of  leeches,  which  each  fresh  appearance  of  local  inflam- 
mation requires,  is  comparatively  less,  and  finally,  the  local  affection,  on 
its  recurrence  in  any  joint,  is  of  such  a  nature,  that  leeching  is  no  longer 


I 


RHEUMATISM.  487 

proper,  while  certaiu  and  almost  immediate  relief  may  be  obtained  from 
blistering.  Blisters  are  better  than  leeches,  not  only  because  they  pos- 
sess the  power  of  removing  pain  and  swelling  with  more  rapidity,  but 
also  because  they  do  not  leave  the  part  in  a  weakened  state.  I  tell  you 
that  blisters  have  a  powerful  effect  in  removing  such  pains,  and  that 
they  may  be  used  in  cases  of  arthritis  where  they  have  not  been  used 
heretofore. 

There  is  another  practical  observation  on  rheumatism  which  I  made 
before  in  the  hospital  wards.  Cases  of  arthritic  rheumatism  will  come 
under  your  notice,  in  which  the  pain  and  fever  are,  from  the  beginning, 
accompanied  by  sweating,  and  this  sweating  is  not  attended  with  any 
relief;  the  pulse  remains  quick,  the  fever  persistent,  and  the  pain  un- 
diminished. This  sweating,  be  assured,  never  tends  either  to  diminish 
fever  or  relieve  pain ;  and  this  is  the  kind  of  arthritis  which  is  most  apt 
to  terminate  in  confirmed  affections  of  the  joints,  and  may  last  for  life. 
From  my  experience  elsewhere,  and  from  the  observations  I  have  made 
in  the  Hospital  for  Incurables,  I  have  remarked,  that  most  of  those  per- 
sons whose  limbs  are  permanently  stiff,  or  even  distorted  from  rheumatic 
affections,  have  been  suffering  for  years  under  this  sweating  arthritis. 
In  one  of  the  patients  at  that  institution,  a  curious  effect  followed 
this  disease.  The  sweating  was  general  over  his  body  at  first,  but  after 
some  time  it  declined  in  the  lower  extremities,  which  seemed  incapable 
of  sweating  any  longer.  The  cuticle  over  these  parts  began  to  exfoliate 
and  become  dry  and  rigid.  A  still  further  change  took  place,  and  the 
lower  extremities  became  covered  with  icthyosis.  He  lies  in  bed  on  his 
back  in  a  helpless  state,  his  legs  and  tliighs  covered  with  a  horny  un- 
yielding cuticle,  but  his  breast  and  face  continue  to  sweat  profusely  as 
before. 

Bear  in  mind,  therefore,  that  this  form  is  liable  to  terminate,  as  I 
mentioned  before,  in  incurable  arthritis.  Some  of  the  senior  students 
may,  perhaps,  recollect  a  poor  man  in  the  chronic  ward  of  this  hospital, 
who  laboured  for  month  after  month  under  this  torturing  malady.  He 
lay  in  a  comer  in  this  state,  and  it  was  a  subject  of  constant  regret  to 
every  body  to  see  him  in  this  pitiable  condition  without  any  prospect  of 
rehef.  Practitioners  are  apt  to  make  a  mistake  in  the  treatment  of  this 
disease.  They  find  the  pulse  quick  but  very  seldom  strong,  and  rather 
forbidding  than  indicating  the  abstraction  of  blood.  How  are  you  to 
treat  such  cases?  By  the  use  of  the  lancet.  Begin,  however,  cau- 
tiously ;  take  away,  at  first,  about  five  or  six  ounces  of  blood,  and  observe 
what  effect  this  produces.  If  your  patient^'s  pulse  is  improved,  his  pain 
lessened,  and  the  sweating  diminished,  you  are  encouraged  then  to  bleed 
more  boldly.     Venesection  is  here  our  sheet  anchor.     You  have  seen 


488  CLINICAL   MEDICINE. 

how  much  rehef  it  gave  the  man  above  stairs,  and  what  a  remarkably 
buffy  coat  his  blood  presented.  His  sweating  was  diminished  con- 
siderably by  this  means ;  and  did  you  remark  how  I  got  rid  of  this 
symptom  entirely  ?  By  giving  him  minute  doses  of  tartar  emetic  and 
opium.  He  had  a  mixture  composed  of  half  an  ounce  of  the  solution 
of  tartarized  antimony,  and  half  a  drachm  of  tincture  of  opium  in  sixteen 
ounces  of  water ;  of  this  he  took  half  an  ounce  every  hour.  It  is  hard 
to  account  for  this,  but  it  is  a  fact,  that  in  some  cases  of  chronic  sweats, 
particularly  those  which  attend  hectic  fever,  you  can  put  a  stop  to  them 
by  giving  a  few  grains  of  Dover^s  powder  at  bed-time. 

There  is  another  very  remarkable  case  at  present  in  the  house  which 
bears  upon  the  observations  I  have  been  now  making ;  I  allude  to  the 
patient  with  sweating  arthritis,  to  whom  I  drew  your  attention  this 
morning.  This  poor  man,  who  is  somewhat  advanced  in  life,  has  been 
labouring  for  several  months  under  inflammation  of  the  joints  of  a 
rheumatic  character,  manifesting  itself  by  pain,  stiffness,  swelling,  and 
probably  some  slight  effusion  into  the  synovial  membranes.  These 
symptoms  were  accompanied  by  profuse  and  constant  perspirations,  with 
a  tendency  to  diarrhoea — circumstances  which  caused  a  manifest  de- 
terioration of  his  health  and  strength ;  he  became  pale,  cachectic  and 
emaciated.  His  case  has  been  very  tedious  and  intractable ;  he  had 
been  a  long  time  in  the  hospital,  and  had  used  all  the  most  appropriate 
remedies,  but  without  any  appreciable  improvement ;  his  joints  remained 
stiff,  painful,  and  almost  useless ;  he  was  greatly  reduced  in  strength, 
and  entirely  confined  to  his  bed.  In  addition  to  this,  his  pulse  con- 
tinued unreduced  in  frequency,  and  this  is  always  a  bad  sign ;  cases  of 
rheumatic  arthritis,  attended  with  prolonged  excitement  of  the  circulation 
and  copious  sweating,  are  generally  found  to  exhibit  an  intractable 
chronicity,  and  too  often  terminate  in  rendering  the  unfortunate  patient 
a  cripple  for  life. 

Now  in  this  case  many  remedies  had  been  tried  without  effect,  and 
the  state  of  the  man^s  constitution,  combined  with  the  circumstance  of 
his  having  a  tendency  to  bowel  complaint,  contributed  to  reduce  still 
further  the  scanty  list  of  our  remedial  agents.  Alterative  remedies,  to 
affect  the  general  system,  were  almost  entirely  out  of  the  question,  and 
a  vast  number  of  local  applications  had  proved  unsuccessful.  It  occurred 
to  me  here,  that  some  benefit  might  be  derived  from  mercurial  ointment, 
gently  rubbed  over  the  affected  parts,  assisting  its  action  by  the  use  of 
rollers  apphed  round  the  joints.  Fortunately,  the  experiment  proved 
successful ;  in  the  course  of  a  week  or  ten  days,  the  swelling  diminished 
considerably,  the  pain  is  nearly  gone,  and  the  power  of  motion  is  return- 
ing. His  mouth  has  become  affected,  but  the  relief  experienced  appears 


RHEUMATISM.  "  489 

to  be  proportioned,  not  to  the  influence  of  mercury  on  the  general 
system,  but  to  its  effect  on  each  individual  joint.  As  a  proof  of  this, 
I  may  state  that  the  man  has  been  mercurialized  before,  but  without  any 
favourable  result. 

Here,  gentlemen,  is  an  important  point  for  consideration.  A  patient 
labours  under  a  certain  number  of  local  inflammations,  for  which 
mercury  is  given  internally,  so  as  to  aff'ect  the  mouth,  but  without  any 
manifest  improvement  of  symptoms ;  we  afterwards  try  the  same  remedy 
in  another  form. ;  we  apply  it  locally,  in  the  shape  of  ointment,  rubbed 
into  the  skin  over  the  diseased  parts,  and  we  succeed  in  giving  relief. 
This  is  a  fact  deserving  of  attention.  You  will  perhaps  ask  me  to  ex- 
plain this — I  cannot  do  it ;  but  I  can  bring  forward  many  other  analo- 
gous examples.  If  you  refer  to  the  late  Mr.  M^DoweFs  valuable  paper 
on  Erysipelas,  published  in  an  early  number  of  the  Bublin  Medical 
Journal,  you  will  find  that  many  cases  of  this  affection  derived  great 
benefit  from  the  use  of  mercurial  ointment;  in  fact,  much  more  than 
they  could  by  giving  mercury  internally. 

In  the  next  place,  I  have  met  with  many  cases  of  enteritis  and  peri- 
tonitis, where  the  disease  continued  after  the  system  became  affected  by 
mercury ;  and  I  have  observed  that  these  cases  yielded  rapidly  to  blis- 
tering the  abdomen,  and  dressing  the  raw  surfaces  with  mercurial  oint- 
ment. Sir  H.  Marsh  and  I  attended  a  young  gentleman  lately,  who  had 
low  fever,  accompanied  by  a  quick  but  feeble  pulse,  and  great  restless- 
ness. About  the  tenth  day,  his  belly  became  tender  and  exquisitely 
painful ;  he  had  thirst,  diarrhoea,  and  other  symptoms  of  enteric  and 
peritoneal  inflammation.  Before  his  illness,  he  had  been  of  rather 
delicate  habit,  and  had  further  impaired  his  health  by  close  study.  He 
was  therefore  unfit  for  depletion,  and  of  this  we  were  convinced  by  the 
debility  which  followed  the  application  of  a  few  leeches.  Under  these 
circumstances,  we  ordered  a  large  blister  to  be  appHed  to  the  abdomen, 
and  the  vesicated  surface  to  be  dressed  with  mercurial  ointment.  This 
proved  eminently  successful;  the  peritonitis,  enteric  irritation,  and 
fever,  soon  disappeared,  and  the  young  gentleman  recovered  completely. 

The  same  thing  is  seen  in  many  cases  of  pleuritis ;  the  constitutional 
effect  of  mercury  will  fail  in  removing  the  affection  of  the  pleura  until  it 
is  applied  locally.  I  might  also  refer  to  instances  of  common  inflamma- 
tion of  the  testicle,  in  which  mercurial  ointment,  smeared  over  the  part, 
has  been  found  decidedly  beneficial.  It  is  unnecessary  for  me,  however, 
to  multiply  examples;  what  I  have  stated  gives  ample  proof  of  the 
utiHty  of  mercury  applied  locally.  When  I  was  a  student,  it  was  the 
fashion  to  scout  the  doctrine  that  any  distinct  effect  could  be  produced 
by  the  local  application  of  mercury ;  our  teachers  laid  it  down  as  an 


490  *  CLINICAL    MEDICINE. 

axiom,  tliat,  to  produce  any  sensible  effect,  it  was  necessary  that  it  should 
first  enter  the  system  tlirough  the  lymphatics.  Thus,  when  you  rub 
mercurial  ointment  over  the  liver  to  remove  hepatic  derangement,  they 
said,  before  it  could  exert  any  influence  on  the  liver  it  had  to  pass  along 
the  thoracic  duct,  become  mixed  with  the  circulation,  and  manifest  its 
peculiar  action  on  the  whole  economy.  Hence,  in  a  case  of  hepatitis  or 
testitis,  it  was  deemed  useless  to  apply  mercurial  ointment  over  the  liver 
or  testicle,  since  it  had,  as  they  expressed  it,  to  go  its  round  through 
the  whole  system,  before  it  could  affect  either  of  these  organs. 

This  reasoning  has  an  appearance  of  plausibility,  but  it  is  contradicted 
by  facts.  Numerous  examples  might  be  cited  to  prove  that  the  greatest 
advantage  may  be  derived  from  the  local  application  of  mercury,  inde- 
pendent of  any  effect  produced  by  it  on  the  general  system.  How  often 
do  we  see  an  incipient  bubo  dispersed  by  mercurial  frictions,  before  any 
constitutional  effects  occur  ?  How  frequently  do  we  see  laryngeal  and 
hepatic  inflammation  relieved  by  the  use  of  mercurial  ointment  without 
salivation  ?  Do  the  beneficial  effects,  which  we  so  often  observe  from 
the  emplastrum  ammoniaci  cum  hydrargyro,  depend  necessarily  upon 
the  mouth  being  affected  ?  Is  the  reHef  which  follows  the  use  of  mer- 
curial ointment  in  erysipelas  or  testitis,  unattainable  unless  preceded  by 
mercurial  action  in  the  whole  system  ?  Indeed,  any  person  who  reviews 
this  subject  dispassionately,  must  see  that  the  doctrine  of  a  preliminary 
constitutional  affection  being  absolutely  necessary,  in  order  to  obtain  the 
specific  action  of  mercury  on  any  particular  organ,  is  wholly  untenable ; 
while,  on  the  other  hand,  there  is  a  host  of  evidence  to  prove  that  locally 
applied,  it  produces  a  primary  and  distinct  effect,  totally  independent  of 
its  action  on  the  general  economy. 

Having  spoken  now  of  the  utility  of  mercury  in  certain  cases 
of  rheumatic  fever,  where  the  inflammation  of  the  joints  will  not 
yield  to  other  means;  I  have  to  add,  that  the  hydriodate  of  potash 
has  been  found  to  be  a  most  useful  adjunct  to  mercury,  and  well  calcu- 
lated for  following  up  and  completing  the  beneficial  effects  produced  by 
that  remedy.  In  fact,  in  treating  arthritic  or  rheumatic  fever,  when  I 
have  reduced  the  violence  of  the  fever  and  of  the  inflammatory  affection 
of  the  joints  by  means  of  bleeding  and  leeching,  followed  by  tartar  emetic 
or  nitre,  or  both  combined,  or  when  after  the  antiphlogistic  treatment, 
both  local  and  general,  I  have  produced  a  marked  alleviation  of  the 
patient's  sufferings,  either  by  the  use  of  colclucum  or  by  the  use  of  mer- 
cury combined  with  opiates, — then,  I  say,  we  can  employ  the  hydriodate 
of  potash  with  the  greatest  possible  advantage,  as  it  quickly  dissipates 
the  remaining  pain  and  swelling  of  the  joints,  and  contributes  powerfully 
to  bring  the  disease  to  a  speedy  termination,  while  at  the  same  time  it 


RHEUMATISM.  '  491 

greatly  diminishes  the  danger  of  a  relapse.  I  have  experienced  much 
comfort  and  feel  much  confidence  in  the  treatment  of  rheumatic  fever 
since  I  adopted  this  practice ;  and  it  now  never  happens  to  me  to  meet 
with  cases  which,  in  spite  of  all  my  efforts,  become  chronic,  and  confine 
the  unfortunate  sufferers  to  bed  for  months.  You  have  observed  re- 
cently, that  in  most  cases  of  acute  rheumatism  affecting  the  joints,  no 
matter  what  mode  of  treatment  I  adopt  in  the  commencement  and  during 
the  acme  of  the  disease,"  I  generally  complete  the  cure  with  the  hydriodate 
of  potash,  beginning  with  doses  of  ten  grains,  which  are  quickly  aug- 
mented to  twenty  or  thirty  grains  three  times  a-day.  It  is  generally 
given  in  decoction  of  sarsaparilla,  to  which  some  preparation  of  morphia 
forms  an  useful  addition. 

Having  said  so  much,  I  shall  make  but  a  few  observations  on  another 
case  of  rheumatic  fever  we  had  lately  in  hospital.  The  patient  had  at 
first  fever  and  inflammation  of  the  joints ;  the  fever  was  removed  by 
appropriate  treatment,  but  the  inflammation  of  the  joints  continued ; 
the  fever  set  in  again  and  the  arthritic  affection  increased,  and  we 
removed  both.  He  relapsed  again,  the  fever  re-appeared,  but  there  was 
no  inflammation  of  the  joints.  Here  we  have  a  man  admitted  with 
rheumatic  fever  and  inflammation  of  the  joints ;  we  try  to  cure  the  dis- 
ease, and  we  succeed  in  removing  the  fever;  but  the  joints  remain 
inflamed ;  we  remove  this  also,  and  congratulate  ourselves  on  a  recovery, 
and  we  again  have  fever  and  arthritic  inflammation;  we  overcome 
tliis  ;  and  again  a  relapse  comes  on  :  but  mark  the  difference,  we  have 
now  fever,  but  the  joints  are  unaffected.  This  is  a  curious  circumstance, 
and  confirms  me  in  an  opinion  I  have  entertained  for  some  time,  that 
we  may  have  rheumatic  fever  without  inflammation  of  the  joints. 

Rheumatic  fever  is  usually  distinguished  by  being  accompanied  with 
pain,  swelling,  and  redness  of  the  joints ;  but  I  have  remarked,  long 
since,  that  this  fever  presents  several  other  peculiarities.  We  have,  as 
in  other  fevers,  great  heat,  occasional  tendency  to  sweating,  and  hard 
quickened  pulse  ;  we  have  the  urine  at  first  pale,  then  high  coloured, 
and  the  blood  buffed.  But  we  have  no  affection  of  the  sensorial  func- 
tions, no  head-ache,  and  when  pain  permits,  rest ;  sleep  is  not  propor- 
tionally impaired,  the  tongue  is  furred,  but  the  appetite  is  frequently 
good,  there  is  no  nausea,  no  disgust  at  food.  These  peculiarities  I  have 
frequently  remarked,  but  it  was  only  lately  that  I  became  aware  that 
this  species  of  fever  may  exist  without  inflammation  of  the  joints.  It  is 
well  known,  that  the  affection  of  the  joints  may  exist  without  the  fever. 
The  combination  of  these  two  distinct,  but  frequently  associated  affec- 
tions, constitutes  the  disease  termed  rheumatic  fever.  This  explains  the 
reason  why  we  must  wait  until  a  certain  period,  until  the  fever  subsides, 


492  CLINICAL   MEDICINE. 

before  we  give  tonics.     We  commence  witli  antiplilogistics,  then  we ' 
employ  specifics,  such  as  mercury  or  colcliicum,  and  afterwards  we  give 
tonics. 

The  case  of  Coghlan,  who  has  been  for  some  time  an  inmate  of  our 
chronic  ward,  demands  a  few  observations.  He  was  admitted  for  an 
attack  of  arthritis  on  the  10th  of  December,  and  since  that  period  has 
been  subjected  to  various  modes  of  treatment.  You  will  recollect  that 
on  his  admission  he  stated  that  he  had  been  attacked  several  times  with 
rheumatic  inflammation  of  the  joints.  Like  most  persons  of  his  class, 
he  has  suffered  greatly  from  repeated  fits  of  illness,  brought  on  by  expo- 
sure to  the  same  causes.  One  of  the  greatest  misfortunes  that  can  fall 
upon  labouring  men,  is  a  severe  attack  of  rheumatic  fever  accompanied 
by  inflammatory  affections  of  the  joints  ;  it  not  only  renders  them 
helpless  and  useless  for  a  considerable  time,  but  also  in  some  cases 
leaves  them  cripples  for  life,  and  in  addition,  the  nature  of  their  em- 
ployment constantly  exposes  them  to  relapses,  which  at  length  bring 
on  incurable  affections  of  the  joints ;  we  have,  moreover,  in  this  young 
man's  case,  a  combination  not  unfrequent  in  patients  of  this  descrip- 
tion, namely,  the  effects  of  cold  on  the  chest  as  well  as  on  the 
joints ;  arthritis  combined  with  inflammation  of  the  bronchial  mucous 
membrane. 

Now  where  the  arthritic  affection  is  very  severe,  and  accompanied  by 
high  fever,  the  addition  of  bronchitis  is  a  great  aggravation.  Every 
time  the  patient  coughs  he  feels  like  one  stretched  upon  the  rack ;  at 
every  convulsive  motion  of  the  chest  a  severe  pang  is  felt  in  every  joint, 
and  the  ordinary  rate  of  suffering  is  increased  to  positive  agony.  A  case 
of  this  kind  is  often  hard  to  be  managed,  even  when  the  disease  is  recent 
and  the  constitution  sound ;  but  when  you  have  to  treat  a  severe  attack 
in  a  person  who  has  repeatedly  laboured  under  the  disease,  and  whose 
vigour  has  been  consequently  impahed,  the  difficulty  is  greatly  increased. 
Here  much  attention  is  required  on  the  part  of  the  physician.  Where 
the  combination  is  met  with  in  a  primary  attack,  I  am  generally  disposed 
to  regard  both  affections  as  of  the  same  character,  and  not  requiring  any 
difference  of  treatment ;  I  therefore  attack  the  arthritis  and  the  bronchitis 
with  the  same  remedies,  that  is  to  say,  venesection,  leeches  to  the  affected 
joints  and  over  the  chest,  and  large  doses  of  nitre  and  tartar  emetic. 
These  remedies,  however,  are  only  calculated  for  the  acute  stage  of  a 
primary  attack,  and  where  the  patient's  strength  is  unimpaired ;  for 
when  the  disease  is  chronic,  and  debility  present,  you  cannot  venture  on 
the  use  of  large  doses  of  tartar  emetic  and  nitre.  In  such  cases  much 
benefit  is  derived  from  the  use  of  colchicum,  particularly  where  the  patient 
labours  under  more  or  less  fever.     The  following  is  the  form  which  I 


I 


RHEUMATISM.  49^3 

am  in  the  habit  of  using,  and  from  which  I  have  occasionally  derived 
much  benefit — 

BL     Misturse  Amygdalarum,  f^viij. 
Aceti  Colchici,  f^ss. 
Acetatis  Morphiae,  gr.  i. 

Nitratis  Potassae,  3ss.  ;  Fiat  mistura,  cujus  sumat  cochleare  unum 
amplum  omni  vel  secunda  quaque  hora. 

In  Coghlan^s  case  we  tried  tliis  mixture  with  local  applications  to  the 
joints  and  a  blister  to  the  chest,  but  found  at  the  end  of  some  days 
that  there  was  no  visible  improvement  in  the  patient.  Now,  whenever 
a  state  of  things  of  this  kind  occurs,  no  time  should  be  lost ;  for,  rely 
on  it,  that  where  colchicum  does  not  afford  relief  in  a  short  time,  and 
in  moderate  doses,  there  is  no  use  in  giving  it  a  further  trial.  You 
have  here  to  contend  with  two  affections  of  a  very  serious  character — 
one  capable  of  rendering  your  patient  a  cripple  for  life,  the  other 
threatening  him  with  suffocation,  from  an  extension  of  the  inflamma- 
tion into  the  minute  bronchial  tubes — an  occurrence  which  is  most 
commonly  followed  by  dangerous  congestion  of  the  lung.  Under  such 
circumstances,  the  only  treatment  you  can  adopt  with  a  hope  of  speedy 
relief  and  ultimate  success,  is  to  lay  aside  all  other  remedies,  and  trust 
almost  exclusively  to  the  use  of  mercury.  In  cases  of  this  kind  do  not 
hesitate  a  moment,  but  mercurialize  your  patient  at  once,  if  his  con-, 
stitution  be  at  aU  capable  of  bearing  it.  The  treatment  which  was 
followed  in  the  case  under  consideration  was  this  : — we  gave  the  patient 
ten  grains  of  hydrargyrum  cum  creta,  four  times  a  day ;  and  with  the 
view  of  relieving  pain  and  the  irritation  of  the  bronchial  mucous  mem- 
brane, he  took  one  drop  of  hydrocyanic  acid,  and  ten  drops  of  tincture 
of  hyoscyamus  in  haK  an  ounce  of  almond  emulsion,  three  times  daily. 

The  next  affection  I  shall  draw  your  attention  to  is  chronic  rheuma- 
tism, of  which  we  have  a  well-marked  instance  in  the  man  who  lies  in 
the  chronic  ward  immediately  under  the  window.  He  complains  of 
pain,  weakness,  and  numbness  of  the  lower  extremities,  for  wliich  he 
used  the  decoction  of  sarsapariUa  and  minute  doses  of  corrosive  subh- 
mate,  for  a  fortnight,  without  any  obvious  improvement  in  his  symp- 
toms. His  complaint  is  of  considerable  duration,  it  being  now  fifteen 
weeks  since  he  was  first  attacked.  This,  I  need  not  tell  you,  is  a  very 
unpromising  feature  in  his  case.  When  rheumatism  has  continued  for 
three  or  four  months,  it  becomes  a  very  intractable  disease ;  indeed, 
there  is  scarcely  any  affection  which  tasks  the  ingenuity,  and  tries  the 
patience  of  a  medical  man  more  than  chronic  rheumatism..    In  this 


494  CLINICAL   MEDICINE. 

case,  however,  we  have  been  so  fortunate  as  to  hit  on  a  remedy  suited 
to  the  complaint ;  the  man  has  been  rapidly  improving  within  the  last 
fortnight,  and  is  now  nearly  well. 

You  will  recollect  that,  when  I  undertook  the  treatment  of  this  case, 
the  patient  was  free  from  fever,  his  general  health  but  little  impaired, 
his  pulse  tranquil,  his  appetite  good,  no  remarkable  tenderness  or  red- 
ness of  the  joints — in  fact,  nothing  to  indicate  the  existence  of  acute 
local  inflammation ;  consequently,  it  would  have  been  useless  to  have 
recourse  to  leeches  or  blood-letting,  or  to  administer  antimonials,  nitre, 
or  colchicum.  In  such  cases  as  this  a  different  line  of  practice  must 
be  followed ;  you  must  have  recourse  to  stimulant  diaphoretics — reme- 
dies which  will  increase  the  secretion  from  the  skin,  at  the  same  time 
that  they  exercise  a  stimulating  action  on  the  nervous  and  capillary 
systems.  Accordingly,  we  prescribed  for  this  man  the  following  elec- 
tuary, of  which  he  was  to  take  a  teaspoonful  three  times  a  day : — Pow- 
dered bark  3j,  powdered  guaiacum  3j,  cream  of  tartar  gj,  flowers  of 
sulphur  3ss,  powdered  ginger  3j,  to  be  made  into  an  electuary  with  the 
common  syrup  used  in  hospitals. 

The  guaiacum  not  only  acts  on  the  nerves,  tending  to  remove  chronic 
pains,  but  also  acts  on  the  skin ;  you  will  find  these,  and  other  proper- 
ties possessed  by  it,  detailed  at  large  in  your  works  on  Materia  Medica. 
Whether  given  in  the  form  of  powder  or  tincture,  it  often  proves  an 
extremely  useful  remedy  in  cases  of  chronic  rheumatism,  where  no  symp- 
toms of  active  local  inflammation  or  general  fever  exist;  where  either 
of  these  are  present  it  is  inadmissible.  Ginger  has  also  a  stimulant 
effect,  although  its  action  is  much  more  more  limited.  It  is  a  favourite 
domestic  remedy,  and  is  very  frequently  prescribed  by  our  rival  candi- 
dates for  therapeutic  celebrity — old  ladies — in  cases  of  chronic,  or,  as 
they  term  it,  cold  rheumatism ;  and  I  must  confess  that  I  have  seen 
some  benefit  derived  from  their  specific — ginger  tea.  With  these  we 
combined  sulphur,  which  exerts  a  peculiar  stimulant  operation  on  the 
skin  and  alimentary  canal.  Sulphur  is  an  extremely  active  remedy,  and 
singularly  penetrating  in  its  nature,  finding  its  way  into  many  of  the 
secretions  and  most  of  the  tissues  of  the  body.  You  will  find  it  in  the 
urine  in  the  form  of  sulphates,  and  it  is  exhaled  from  the  skin  and 
mucous  membrane  of  the  bowels  in  the  form  of  sulphuretted  hydrogen. 
Having  said  so  much  respecting  sulphur,  you  will  perhaps  inquire  why 
I  prescribed  the  bark  ?  It  is  not  easy  to  give  a  satisfactory  explanation 
of  this ;  but  we  know,  from  experience,  that  in  cases  of  rheumatism, 
after  fever  and  local  inflammation  are  removed,  bark  and  other  tonics 
have  been  found  extremely  valuable.  The  cream  of  tartar  is  given  with 
the  view  of  tempering  the  other  stimulant  remedies,  it  being  known  to 


SCIATICA    AND    LUMBAGO.  495 

possess  cooling  and  aperient  properties.  The  whole  form  a  combination 
which  is  similar  in  its  composition  to  a  well-known  popular  remedy  for 
rheumatism — the  Chelsea  Pensioner. 

Having  thus  explained  the  general  tendency  of  these  medicines,  and 
mentioned  that  they  are  to  be  made  up  into  an  electuary,  it  only  remains 
to  speak  of  the  effect  produced,  and  the  dose  or  quantity  to  be  given. 
I  have  stated  that  the  ordinary  dose  is  a  teaspoonful  three  times  a-day ; 
this,  however,  will  be  too  much  for  some,  and  too  little  for  others.  The 
object  in  every  case  should  be  to  keep  up  a  mild  but  steady  action  on 
the  bowels,  and  to  procure  a  full  alvine  discharge  at  least  once  a-day. 
If  the  dose  mentioned  already  does  not  answer  this  purpose,  it  must  be 
increased ;  if  the  bowels  are  too  free,  it  must  be  diminished.  You  should 
never  omit  making  regular  inquiries  after  the  state  of  the  bowels,  while 
the  patient  is  using  this  electuary  ;  for,  if  these  matters  are  neglected, 
the  patient  will  not  obtain  the  full  benefit  to  be  derived  from  it.  Besides 
opening  the  bowels,  this  electuary  acts  on  the  skin,  and  frequently 
causes  a  rapid  disappearance  of  the  disease.  I  need  not  say  that,  in 
addition  to  this,  I  ordered  warm  baths ;  they  coincide  in  effect  with 
the  electuary,  acting  on  the  skin,  and  tending  to  relieve  the  rheumatic 
pains. 

I  shall  now  conclude  with  some  observations  on  the  treatment  of 
sciatica  and  lumbago  affections  closely  allied  to  rheumatism.  In  acute 
and  subacute  lumbago  and  sciatica,  the  most  approved  treatment  con- 
sists of  antiphlogistic  measures,  particularly  blood-letting,  general  and 
local,  followed  by  the  exhibition  of  antimonials  and  Dover's  powder 
in  proper  doses.  Cupping  the  lumbar  region  (when  the  operation  is 
skilfully  performed)  deservedly  enjoys  a  high  reputation  in  lumbago ; 
and  if  sciatica  is  present,  the  tender  parts  about  the  buttock  and 
thigh  must  likewise  be  repeatedly  cupped.  In  the  latter  case,  it  is 
requisite  to  have  a  very  small  scarificator,  and  cups  of  a  corresponding 
size,  so  as  to  enable  the  operator  to  follow  the  track  of  the  sciatic  nerve. 
In  Germany  they  generally  use  instruments  so  small,  that  ten  or  twelve 
of  the  glasses  may  be  placed  close  to  each  other,  in  a  line  extending 
along  the  painful  portion  of  the  nerve,  where  it  Hes  most  superficially 
in  the  thigh.  This  practice  deserves  more  general  imitation  in  this 
country. 

That  popular  remedy,  a  warm  bath,  often  forms  a  most  excellent 
adjuvant  to  these  measures,  and  is  stiU  more  efficacious  when  preceded 
by  a  powerful  warm  douche.  A  stream  of  hot  water,  played  with  con- 
siderable force  against  the  loins,  buttock,  and  thigh,  seems  to  act,  not 
merely  by  the  heat  it  imparts,  but  also  by  the  mechanical  impulse  it 


496  CLINICAL   MEDICINE. 

exerts,,  an  impulse  wliicli  may  be  termed  water-cham/pooing  ;  in  Dublin, 
such  a  douche  and  warm  bath  may  be  had  at  the  Northumberland 
Buildings.  The  means  just  enumerated,  combined  with  absolute  rest  in 
bed,  well  succeed  in  many  cases ;  in  others  they  will  fail,  and  then  this 
question  arises, — what  ought  we  to  try  next  ?  In  some  cases  I  have 
followed  the  example  of  Dr.  Percival  and  Dr.  Cheyne,  of  giving  two  or 
three  grains  of  opium  in  the  day,  combined  with  calomel  and  James''s 
powder,  and  with  much  benefit. 

In  a  case  of  lumbago  and  sciatica,  which  I  treated  with  Mr.  White, 
the  disease  at  first  neglected  had  passed  from  a  chronic  to  an  acute 
state,  and  had  become  painful  to  the  greatest  possible  degree ;  in  truth, 
the  patient^s  agony  was  quite  excruciating,  and  though  a  man  of  strong 
mind  and  vigorous  nerves,  the  sweat  poured  down  his  face  from  the 
suffering  he  endured  whenever  it  was  necessary  to  move  himself  in  bed, 
or  even  when  the  floor  of  the  room  was  shaken  by  any  person  treading 
heavily. 

As  our  patient  had  been  repeatedly  cupped,  and  the  usual  remedies 
had  completely  failed,  Mr.  White  proposed  a  combination  of  three 
grains  of  acetate  of  morphia,  six  grains  of  calomel  and  twelve  of  James's 
powder,  divided  into  eight  portions,  one  to  be  taken  every  third  hour ; 
the  good  effects  of  this  combination  w^ere  so  striking,  that  I  have  since 
had  recourse  to  it  repeatedly,  and  there  is  no  one  remedy  in  which  I 
have  greater  confidence.  Still,  however,  it  is  liable  to  the  objection, 
that  it  must  generally  be  continued  until  thie  gums  become  tender,  or 
even  the  mouth  slightly  sore,  an  objection  not,  it  is  true,  of  much 
weight  in  cases  like  the  preceding,  where  the  disease  is  very  acute,  and 
the  patient  necessarily  confined  to  his  bed ;  but  which  renders  this  com- 
bination quite  inapplicable  in  sub-acute  or  chronic  attacks,  where  the 
sufferer  tries  to  pursue  his  ordinary  avocations,  and  is  necessarily  ex- 
posed, more  or  less,  to  the  open  air ;  to  such  persons  hydrlodate  of 
potash  will  prove  most  valuable. 

I  first  became  acquainted  with  the  remarkable  efficacy  of  this  medi- 
cine in  lumbago  and  sciatica,  under  the  following  circumstances.  In 
the  memorably  wet  month  of  July,  1839,  I  was  called  out  of  bed  at 
midnight,  to  visit  a  lady  in  the  country,  and  the  vehicle  sent  to  convey 
me  was  a  hack  covered  car.  The  cushions  were  very  damp,  and  I  had 
not  proceeded  half  a  mile  before  I  was  attacked  with  lumbago  so  severe 
that  I  could  scarcely  walk  when  I  arrived  at  my  patient's  residence. 
Next  morning  I  was  better,  having  perspired  much  during  the  night ; 
but  still  the  pain  was  troublesome,  and  as  the  season  continued  un- 
usually cold  and  wet,  (indeed  it  scarcely  ever  stopped  raining  from  the 
8th  of  July,  1839,  to  the  19th  of  February,  1840,)  aud  as  my  duties 


SCIATICA.    AND    LUMBAGO.  497 

exposed  me  much  to  the  weather,  and  prevented  me  from  giving  myself 
the  necessary  rest_,  my  lumbago  continued  to  increase  again,  and  in 
about  a  month,  the  gluteal  and  sciatic  nerves  of  the  left  side  became 
engaged;  I  noted  particularly,  that  the  pain  spread  very  gradually 
downwards  from  the  lumbar  region,  so  that  it  took  a  week  or  ten  days 
to  arrive  at  the  ham,  and  still  a  longer  time  at  the  ankle ;  I  was  then 
quite  lame  of  the  left  leg,  suffered  much  pain  in  bed,  and  had  become 
so  helpless,  that  I  had  to  get  my  servant  to  draw  on  my  stockings ; 
during  all  this  time  my  general  health  was  perfect;  appetite  good; 
digestion  regular;  and  no  deviation  of  the  urine  from  the  natural 
appearance.  I  mention  this  because  several  of  my  medical  friends 
advised  me  to  take  antibilious  aperients,  an  advice  founded  on  Aber- 
nethy's  doctrine,  that  many  local  affections  proceed  from  stomach 
derangement. 

I  was  at  last  forced  to  try  something  for  my  relief,  and  had  myself 
cupped,  and  tried  the  warm  douche  and  Dover's  powder,  but  without 
any  good  effects.  I  began  now  to  fear  that  I  should  be  forced  to  give 
up  all  professional  business,  and  confine  myself  to  the  house  for  many 
weeks  in  order  to  go  through  a  mercurial  course,  combined  with  proper 
topical  applications,  when  happening  to  meet  the  late  Mr.  Terguson  of 
Kildare-street,  he  recommended  me  to  try  hydriodate  of  potash,  of 
which  he  was  good  enough  to  send  me  a  drachm  dissolved  in  a  pint  of 
decoction  of  sarsaparilla.  I  took  quarter  of  this  daily,  and  may  literally 
apply  here  the  common  phrase,  that  I  felt  each  dose  do  me  good ;  in 
truth  the  benefit  I  derived  was  perceptible  hourly,  and  was  so  rapid, 
that  in  four  days  all  traces  of  the  lumbago  were  gone,  and  my  lameness 
had  quite  ceased.  I  did  not  take  more  than  one  bottle — one  drachm 
of  tlie  hydriodate,  but  the  good  effect  continued  after  I  had  ceased 
taking  it,  and  in  less  than  a  week,  I  was  perfectly  well.  Subsequent 
experience  enables  me  to  recommend  this  medicine  strongly,  in  sub- 
acute and  chronic  lumbago  and  sciatica. 

It  is  right  to  observe,  that  the  remedy  had  in  my  own  person  to 
work  against  various  disadvantages,  for  I  neither  relaxed  from  my 
labours,  nor  refrained  from  eating  and  drinking  as  usual.  This  is  only 
another  example  of  the  many  I  have  met,  which  prove  how  injudicious 
it  often  is,  to  seek  the  cure  of  local  inflammations  by  means  of  lowering 
the  whole  system. 

In  spite  of  the  best  directed  means,  sciatica  is  very  apt  to  become 
chronic,  and  then  oil  of  turpentine,  carbonate  of  iron,  arsenic,  extract 
of  stramonium,  corrosive  sublimate,  blue  pill  and  iodine  internally, 
blisters  to  the  loins,  thigh  and  calf  of  the  leg,  acupuncture,  croton  oil 
frictions,  and  other  stimulating  applications  must  be  successively  tried. 
VOL.  I.  S2 


498  CLINICAL  MEDICINE. 

On  a  former  occfrsion  I  recommended  a  combination  of  opium^  with  oil 
of  turpentine  internally,  and  when  that  fails,  Dover's  powder,  combined 
with  sulphate  of  quina.  I  am  sorry  not  to  have  it  in  my  power  to 
lay  down  any  general  principle,  which  would  enable  you  to  judge  in 
what  cases  each  of  these  remedies  is  peculiarly  indicated,  for  experience 
has  not  confirmed  any  of  the  rules  generally  relied  on,  and,  therefore, 
we  must  content  ourselves  with  treating  these  diseases  empirically. 

Change  of  climate  and  the  use  of  the  Bath,  Buxton,  Harrowgate, 
and  Tunbridge  spa  waters,  have  proved  serviceable  to  many,  while 
others  have  been  obliged  to  have  recourse  to  the  natural  hot  baths  of 
Bagneres  or  Bareges.  In  very  obstinate  cases,  the  practice  long 
adopted  in  the  surgical  wards  of  the  Meath  Hospital,  is  to  apply  the 
actual  cautery  to  five  or  six  spots  along  the  course  of  the  painful  nerve. 
The  application  ought  to  be  rather  severe,  so  as  to  produce  moderately 
sized  sores  which  must  be  kept  open  for  a  fortnight  or  tliree  weeks,  by 
suitable  dressings.  This  is  a  very  painful  process,  and  for  several  days 
after  the  application  of  the  cautery,  the  patient  suffers  much,  and  often 
thinks  the  disease  to  be  aggravated ;  after  some  time,  however,  im- 
provement becomes  perceptible ;  and  on  the  whole,  I  do  not  think  any 
other  remedy  is  so  much  to  be  relied  on  in  very  obstinate  cases  of 
sciatica. 

An  observation  made  by  Dr.  Grogan,  is  worth  recording  here,  as  it  bears 
on  a  physiological  question.  In  a  patient  of  his,  a  young  man  of  robust 
constitution,  who  suffered  for  more  than  a  year,  much  pain  from  an  imper- 
fectly cured  sciatica,  the  affected  thigh  and  calf  were  much  subject  to 
spasmodic  pains,  and  muscular  twitchings.  These  sometimes  continued 
night  and  day,  and  in  consequence  of  these  morbid  contractions  con- 
stantly recurring,  the  muscular  fibres  became  hypertrophied,  and  the 
whole  limb  became  much  developed,  presenting  a  more  athletic  outline, 
and  exceeding  its  fellow,  considerably  in  bulk.  This  fact  which  was 
pointed  out  to  me  by  Dr.  Grogan  is  very  remarkable ;  for,  in  general, 
chronic  sciatica  induces  a  flaccid  and  atrophied  state  of  buttock,  thigh, 
and  calf.  In  the  case  referred  to,  the  hypertrophy  disappeared  in  less 
than  a  month  after  the  actual  cautery  had  been  applied. 

As  the  practical  physician  ought  not  to  neglect  any  circumstance, 
however  trivial  it  may  appear,  which  bears  upon  the  health  of  his 
patients,  the  following  hints  should  not  be  regarded  as  too  trifling  for 
notice.  Persons  subject  to  lumbago  ought,  as  much  as  possible,  avoid 
remaining  for  any  length  of  time  in  a  flexed  or  stooping  position,  par- 
ticularly if  exposed  to  cold ;  it  is  for  this  reason  that  lumbago  so  fre- 
quently attacks  gentlemen,  while  engaged  in  the  act  of  shaving.  Those 
who  are  liable  to  the  disease,  therefore,  must  be  careful  either  to  shave 


SCIATICA    AND    LUMBAGO.  499 

while  sitting  before  the  glass,  or  if  standing,  let  the  glass  be  placed  so 
high  that  thej  may  stand  quite  straight.  Again,  many  are  attacked 
while  drawing  on  their  boots;  tliis  accident  may  be  surely  avoided  by 
using  boot-hooks,  with  shanks  about  fourteen  inches  long,  so  that  the 
body  and  tliigh  may  be  nearly  in  the  same  line,  when  the  effort  to  draw 
on  the  boot  is  made.  Persons  who  are  in  dread  of  lumbago  and 
sciatica,  ought  always  to  wear  stout  drawers,  whose  waistband  should 
be  broad  and  consist  of  a  strong,  warm,  yet  elastic  material,  so  as  to 
allow  it  to  be  worn  very  tight  without  inconvenience. 


500 


DISEASES  OF  THE  BRAIN  AND  NEKYOUS  SYSTEM. 


LECTURE  XXXIII. 

PATHOLOGY    OF    NERVOUS   DISEASES. 

Before  I  proceed  to  speak  of  diseases  of  the  brain  and  spinal  cord, 
I  -wish  to  draw  your  attention  generally  to  the  pathology  of  nerv- 
ous diseases.  The  subject  is  interesting,  and  one  on  which  my  opinious 
differ  from  some  of  those  generally  received.  The  observations  I  am 
about  to  make  will  involve  the  consideration  of  the  general  principles 
suited  to  guide  us  in  the  difficult  study  of  nervous  affections,  rather 
than  the  description  of  any  particular  disease.  In  considering  the 
symptoms  that  accompany  diseases  of  the  nerves,  pathologists  have 
directed  their  attention  almost  exclusively  to  the  nervous  centres,  and 
have  looked  on  the  brain,  cerebellum,  and  spinal  cord  as  the  parts  in 
which  the  causes  of  all  nervous  disorders  reside,  or  in  which  they  ori- 
ginate. If  you  examine  the  works  of  Rostan,  Lallemand,  Abercrombie, 
and  all  those  who  have  written  on  diseases  of  the  nervous  system,  you 
will  find  that  their  inquiries  consist  in  searching  after  the  causes  of 
functional  changes,  either  in  the  cerebrum,  cerebellum,  or  spinal  mar- 
row, forgetting  that  these  causes  may  be  also  resident  in  the  nervous 
cords  themselves,  or  their  extremities,  wliich  I  shaU  call  their  circum- 
ferential  jparts. 

When  we  recollect  the  manner  in  which  the  nervous  system  grows, — 
when  we  call  to  mhid  the  fact,  that  in  the  development  of  that  system 
during  the  foetal  state,  the  nervous  extremities  and  trunks  are  formed 
before  any  traces  of  the  brain  are  discernible,  we  must  at  once  allow  it 
is  by  no  means  improbable,  that  these  parts  may  become  incapable  of 
discharging  their  functions  in  consequence  of  changes  originating  in 
themselves,  and  not  proceeding  from  the  nervous  centres.  In  a  word, 
may  not  the  decay  and  withering  of  the  nervous  tree  commence  occa- 
sionally in  its  extreme  branches  ?  and  may  not  a  blighting  influence 
affect  the  latter,  while  the  main  trunk  remains  sound  and  unharmed  ? 

In  fact,  gentlemen,  pathologists  have,  with  respect  to  diseases  of  the 
nervous  system,  committed  an  error  precisely  similar  to  that  which  was 


PATHOLOGY    OF    NERVOUS    DISEASES.  501 

SO  loijg  prevalent  with  regard  to  diseases  of  the  vascular  system  ;  for  it 
is  onlj  lately  that,  in  estimating  the  forces  which  influence  the  circu- 
lation in  diseased  parts_,  they  have  begun  to  appreciate  the  preponderat- 
ing influence  of  the  capillary  vessels,  independently  of  the  heart's  action 
and  the  vis  a  tergo.  It  is  only  lately  that  they  have  recognized  the 
important  truth,  that  diseased  vascular  action  may  commence  in  the 
circumference. 

I  am  willing  to  allow,  that  in  most  cases  of  general  paralysis,  the 
affection  of  the  muscular  system  is  produced  by  disease  of  the  nervous 
centres;  yet,  I  think  it  is  also  evident,  that  an  injury  of  the  extremities 
or  circumferential  parts  of  the  nerves,  may  cause  such  a  derangement 
of  their  functions  as  to  give  rise  to  paralysis.  The  reason  why  persons 
seek  for  the  explanation  of  paralytic  symptoms  by  referring  them  to  the 
nervous  centres,  rather  than  their  peripheral  extremities  is,  because  this 
mode  of  inference  accounts  more  satisfactorily  for  the  simultaneous  affec- 
tion of  many  parts  of  the  system.  Thus,  if  one  hemisphere  of  the 
brain,  or  both,  or  if  the  cerebellum  or  spinal  cord  be  pressed  or  in- 
jured, those  parts  which  have  a  nervous  connexion  with  them  will  expe- 
rience a  corresponding  derangement  of  function.  But  if  a  process 
of  disordered  action  be  set  up  in  one  part  of  the  nervous  extremities, 
and  this  passes  on  to  another  part,  the  translation  seems  very  strange, 
and  you  cannot  easily  comprehend  why  paralysis  of  one  principal  part 
will  produce  the  same  disease  in  another. 

It  has  been  asked,  whether  a  local  paralysis  ever  can,  by  spreading 
towards  the  centre  of  the  nervous  system,  produce  paralysis  in  another 
and  a  distant  locality.  This  is  a  question  we  are  not  in  the  habit  of 
investigating ;  and  I  think  it  has  never  been  sufficiently  or  satisfactorily 
examined,  considering  its  importance  in  a  practical  point  of  view,  and 
the  new  light  which  it  may  throw  on  many  of  the  most  obscure  and 
perplexing  forms  of  disease.  I  shall  endeavour  to  prove,  first,  that 
paralysis  (from  whatsoever  cause  it  may  arise)  affecting  one  portion  of 
the  circumferential  extremities  of  the  nerves,  may  also  affect  other  por- 
tions of  their  extremities ;  secondly,  that  pain  originating  in  one  situa- 
tion may  produce  a  similar  sensation  in  distant  parts ;  and  thirdly,  that 
convulsions  resulting  from  irritation  in  any  part  of  the  extremities  of 
the  nervous  system  may  occasion  a  corresponding  train  of  symptoms  in 
other  parts  of  the  body.  You  perceive,  gentlemen,  that  I  have  enu- 
merated the  three  most  remarkable  symptoms  resulting  from  disease  of 
the  nervous  system,  namely  paralysis,  pain,  and  convulsions.  If  I 
succeed  in  showing  that  each  of  these  may  be  produced  by  causes  acting 
on  the  extremities  of  the  nervous  system  at  a  distance  from  the  part 
affected,  the  position  I  have  advanced  will  be  proved. 


502  CLINICAL   MEDICINE. 

A  few  days  ago,  happening  to  call  at  a  gentleman's  house,  I  was  told 
by  a  young  lady  that  she  had  wounded  the  inside  of  the  ring  finger 
with  a  blunt  needle,  and  that  she  found  in  it  a  considerable  degree  of 
numbness  and  loss  of  sensation.  I  said  to  her,  "  your  little  finger  is 
also  numb/'  You  are  aware  these  two  fingers  are  supplied  by  the  same 
branch  of  the  ulnar  nerve.  Well,  the  little  finger  was  really  numb,  as 
well  as  the  finger  next  to  it,  which  had  been  injured.  What  were  the 
circumstances  of  the  case  in  this  instance  ?  The  side  of  the  ring  finger 
next  to  the  little  finger  had  been  wounded  with  a  blunt  needle ;  the 
impression  made  on  the  nervous  extremities  of  the  side  of  one  finger 
produced  numbness  not  only  in  that  finger,  but  also  the  same  cause 
operated  backwards,  or  towards  the  centre,  so  as  to  affect  the  branch 
given  off  to  supply  the  httle  finger,  by  the  ulnar  nerve,  above  the  place 
of  the  wound.  Here  is  an  instance  of  a  cause  producing  numbness  of 
a  particular  branch  of  a  nerve,  occasioning  the  same  affection  in  another 
branch,  and  giving  rise  to  phenomena  identical  with  those  which  might 
arise  from  an  injury  of  the  main  branch  of  the  ulnar  nerve.  This  is  a 
plain  fact. 

You  have  a  case  of  precisely  the  same  paralysis  in  a  poor  woman  in 
this  hospital,  who  has  been  complaining  of  rheumatic  pains  in  various 
parts  of  her  body.  Before  I  had  been  struck  by  these  and  other  in- 
stances of  the  same  kind,  I  looked  for  the  cause  of  this  paralysis  in  the 
trunk ;  now  I  can  understand  how  it  may  be  in  the  periphery.  You 
recollect  I  made  some  observations  before  on  this  subject,  and  men- 
tioned that  this  numbness  is  frequently  remarked  in  cases  of  gout  and 
rheumatism,  and  that  this  occurrence  in  old  persons  often  excites  appre- 
hensions of  approaching  paralysis.  I  have  known  old  gentlemen  so 
alarmed  by  it,  as  to  seek  medical  advice ;  and  as  this  affection  some- 
times precedes  gout,  and  sometimes  accompanies  rheumatic  arthritis  and 
phlegmasia  dolens,  it  is  a  fact  worthy  of  your  attention,  and  one  which 
I  would  recommend  you  to  hold  in  memory,  though  I  must  confess  I 
am  not  able  to  give  any  explanation  of  it.  I  have  seen  an  attack  of 
this  peripheral  paralysis  in  a  gentleman  of  gouty  habit,  and  heard  him 
express  a  great  deal  of  surprise  when  he  was  told  by  Mr.  Kirby,  his 
medical  attendant,  that  it  would  usher  in  a  fit  of  his  complaint.  This 
gentleman,  however,  after  taking  some  warm  stimulant  medicine^  went 
to  bed,  and  next  morning  had  a  regular  attack  of  gout. 

But  to  return  to  our  subject.  If  you  make  experiments  by  handhng 
snow,  or  immersing  your  hands  in  freezing  mixtures,  or  any  fluid  of 
very  low  temperature,  you  find  that,  after  some  time,  the  exposed  parts 
lose  first  the  power  of  sensation,  and  afterwards  that  of  motion,  and  that 
in  this  way  you  produce  a  complete,  though  temporary,  local  paralysis. 


PATHOLOGY    OF   NERVOUS    DISEASES.  5-03 

Of  this  fact  you  are  all  aware.  But  what  bears  more  strongly  on  the 
subject  in  question  is  that  the  paralysis  thus  induced,  is  not  merely 
confined  to  the  hands  and  fingers,  but  also  extends  to  other  parts.  You 
not  only  have  the  hands  and  fingers  numb,  but  also  lose,  in  a  great 
degree,  the  power  of  flexion  and  extension,  which  is  seated  in  the  mus- 
cles of  the  fore-arm,  and  the  motions  of  the  wrist-joint,  are  imperfectly 
performed.  Now  all  this  time  the  muscles  of  the  fore-arm,  lying  at  a 
considerable  depth,  and  covered  by  warm  clothing,  are  protected  from 
cold,  and  yet  you  perceive  they  partake  in  the  paralytic  afi*ection  of  the 
exposed  parts.  Here,  then,  is  another  example  of  the  same  nature,  cor- 
roborating our  former  position,  that  causes,  producing  loss  of  power  in 
one  part  of  the  extremities  of  the  nervous  system,  may  have  not  merely 
a  local  influence,  but  also  travel  towards  the  centre  and  affect  distant 
parts. 

Speaking  of  the  influence  of  cold  on  the  system,  I  have  to  observe, 
that,  from  the  experiments  made  on  this  subject  by  Hunter,  Edwards, 
Dr.  Marshall  Hall  and  others,  some  instances  of  its  effects  seem  very 
singular.  One  of  the  most  remarkable  is  the  production  of  paralysis, 
which,  in  most  cases,  is  partial,  but  is  sometimes  very  general  without 
being  followed  by  death.  I  remember  the  case  of  a  dog,  which  lay 
buried  in  snow  for  two  days,  and  was  then  taken  out  quite  stiff  and  in- 
sensible, and  thrown  on  a  dunghill  as  if  dead.  After  some  time  the 
poor  animal  gave  some  symptoms  of  reanimation,  and  finally  recovered. 
The  influence  of  cold  has  been  alluded  to  by  Dr.  Abercrombie,  and  you 
will  find,  that  he  mentions  a  case  of  paraplegia,  arising  from  paralysis 
brought  on  by  cold,  which  lasted  for  eight  months.  A  blast  of  cold 
air  on  one  side  of  the  face  has  been  known  to  cause  paralysis  and  dis- 
tortion of  several  months^  duration. 

Again,  you  have,  as  in  the  case  of  a  man  in  this  hospital,  paralysis  of 
the  lower  extremities  from  exposing  the  feet  to  cold  and  wet,  while  em- 
ployed in  bailing  out  water  in  a  quarry.  You  may  have  observed  the 
same  thing  brought  on  by  similar  exposure  in  fishing  or  snipe  shooting, 
and  that  such  causes  gave  rise  to  paralysis,  not  only  in  the  parts  sub- 
jected to  the  influences  of  diminished  temperature  and  wet,  but  even 
extended  to  the  nervous  centres,  so  as  to  produce  decided  paraplegia. 
I  was  once  myself  exposed  to  a  very  intense  degree  of  cold  on  board  a 
ship,  and  observed  that  the  sailors,  who  had  been  most  exposed,  suffered 
severely,  and  did  not  recover  from  its  effects  during  the  rest  of  our  voy- 
age. In  fact,  many  months  will  often  pass  away  before  the  symptoms, 
arising  from  cold,  are  removed,  and  you  will  find,  that,  in  addition  to 
the  case  of  paraplegia  from  cold,  which  lasted  eiglit  months.  Dr.  Aber- 
crombie mentions  another,  in  which  the  paralysis  was  permanent. 


504  CLINICAL   MEDICINE. 

One  of  the  most  remarkable  examples  of  disease  of  the  nervous  sys- 
tem, commencing  in  the  extremities,  and  having  no  connexion  with 
lesions  of  the  brain,  or  spinal  marrow,  was  the  c\irious  epidemie  de  Paris, 
which  occurred  in  the  spring  of  1828.  Chomel  has  described  this  epi- 
demic in  the  9th  Number  of  the  Journal  Hebdomadaire,  and  having 
witnessed  it  myself,  in  the  months  of  July  and  August,  of  the  same 
year,  I  can  bear  testimony  to  the  abihty  and  accuracy  of  his  description. 
It  began  (frequently  in  persons  of  good  constitution)  with  sensations 
of  pricking  and  severe  pain  in  the  integuments  of  the  hands  and  feet, 
accompanied  by  so  acute  a  degree  of  sensibility,  that  the  patients  could 
not  bear  these  parts  to  be  touched  by  the  bed-clothes.  After  some 
time,  a  few  days,  or  even  a  few  hours,  a  diminution,  or  even  abolition 
of  sensation  took  place  in  the  affected  members,  they  became  incapable 
of  distinguishing  the  shape,  texture,  or  temperature  of  bodies,  the  power 
of  motion  dechned,  and  finally  they  were  observed  to  become  altogether 
paralytic.  The  injury  was  not  confined  to  the  hands  and  feet  alone, 
but  advancing,  with  progressive  pace,  extended  over  the  whole  of  both 
extremities.  Persons  lay  in  bed  powerless  and  helpless,  and  continued 
in  this  state  for  weeks  and  even  months. 

Every  remedy  which  the  ingenuity  of  the  Erench  practitioners  could 
suggest  was  tried,  and  proved  ineffectual.  In  some,  the  stomach  and 
bowels  were  deranged,  and  this  affection  terminated  in  a  bad  state  of 
health,  and  even  in  death ;  in  others,  the  vital  organs,  cerebral,  respi- 
ratory, and  digestive,  were  in  the  same  state  as  before  their  illness,  and 
their  appetites  were  good ;  but  still  they  remained  paralytics.  At  last, 
at  some  period  of  the  disease,  motion  and  sensation  gradually  returned, 
and  a  recovery  generally  took  place,  although,  in  some  instances,  the 
paralysis  was  very  capricious,  vanishing  and  again  re-appearing. 

The  Prencli  pathologists,  you  may  be  sure,  searched  anxiously  in  the 
nervous  centres  for  tlie  cause  of  this  strange  disorder,  but  could  find 
none ;  there  was  no  evident  lesion,  functional  or  organic,  discoverable 
in  the  brain,  cerebellum,  or  spinal  marrow.  Now,  here  is  another  re- 
markable instance  of  paralysis  creeping  from  the  extremities  towards 
the  centre ;  here  is  a  paralysis  affecting  all  parts  of  the  extremities  as 
completely  as  if  it  had  its  origin  in  the  central  parts  of  the  nervous 
system,  and  can  any  one,  with  such  palpable  evidence  before  him,  hesi- 
tate to  believe  that  paralysis,  or  even  hemiplegia,  without  any  lesion  of 
the  brain  or  spinal  cord,  may  arise  from  disease  commencing  and  origi- 
nating in  the  nervous  extremities  alone  ? 

I  may  observe,  en  passant,  that  where  paralysis  simultaneously  attacks 
the  arm  and  leg  of  the  same  side,  it  arises  from  an  impression  on  tlie 
nervous  centres ;  but  this  I  think  does  not  hold  where  the  paralysis  is 


PATHOLOGY    OF    NERVOUS    DISEASES.  505 

creeping^  as  in  the  case  before  me,  which  has  been  reported  by  Mr. 
Pludson,  and  was  under  the  care  of  Dr.  Stokes.  "  The  patient,  James 
Moore,  was  admitted  on  the  4th  of  March,  labouring  under  paraplegia, 
which  he  attributed  to  cold  and  wet.  About  a  month  before  admission 
he  first  perceived  a  stiffness  of  the  great  toe  of  the  right  foot ;  after- 
wards numbness  and  coldness  of  the  sole,  and  then  of  the  leg  as  far  as 
the  knee,  and  dragging  of  the  limb  in  walking.  During  the  progres- 
sion of  the  disease  up  along  the  thigh,  it  commenced  in  the  left  foot, 
and,  after  a  few  days,  he  experienced  almost  complete  paralysis  of  sen- 
sation in  the  right  lower  extremity,  and  a  lesser  degree  in  the  left, 
accompanied  by  so  much  diminution  of  the  power  of  motion,  as  to 
render  him  unable  to  walk  without  support.  About  tliree  weeks  after 
the  appearance  of  paralysis  in  the  lower  extremities,  the  little  finger 
of  the  right  hand  was  attacked  with  numbness,  which  passed  succes- 
sively to  the  rest,  attended  with  some  loss  of  the  sense  of  touch,  and 
power  of  grasping  objects.  He  has  also  had  retention  of  urine,  and 
the  bowels  were  obstinately  constipated.  There  was  no  tenderness  of 
any  part  of  the  spine.  He  had  no  pain  in  the  head.  His  pupils  were 
natural,  mind  unaffected,  pulse,  sleep,  and  appetite  also  natural.^^  Here, 
gentlemen,  you  have  an  instance  of  what  I  would  term  creeping  para- 
lysis, having  its  origin  evidently  in  an  affection  of  the  peripheral  extre- 
mities of  the  nerves. 

I  may  now  observe,  that  I  have  brought  forward  instances  to  prove 
that  direct  injury  of  one  part  of  the  nervous  system  may  produce  para- 
lysis in  another  and  distant  part,  but  have  we  not  also  other  instances  ? 
certain  substances,  which  produce  morbid  aff'ections  on  the  nervous 
system,  are  found  to  be  attended  with  results  analogous  to  those  described. 
You  are  all  aware  that  lead  frequently  brings  on  paralysis ;  that  this  is 
caused  by  the  local  application  of  lead,  and  that  the  effect  of  the  local 
application  extends  chiefly  to  those  parts  to  which  the  lead  is  directly 
applied.  Thus,  in  painter's  colic,  the  paralysis  almost  invariably  begins 
in  the  hands  and  wrists,  preceded,  I  will  allow,  in  many  cases,  by  symp- 
toms of  poisoning  of  the  system,  as  shown  by  the  tormina  and  affection 
of  the  intestinal  canal.  Dr.  Bright  has  remarked,  that  in  painter's 
colic,  the  spine  is  frequently  tender  in  the  cervical  region,  when  the 
upper,  and  in  the  lumbar,  when  the  lower  extremities  are  affected.  It 
has  been  remarked,  that  spinal  tenderness  is  often  the  consequence  of 
disease  of  the  extremities,  and  not  the  cause ;  so,  I  think,  it  is  in 
painter's  colic. 

We  found  in  this  hospital  a  great  number  of  cases  in  which  there 
was  paralysis  of  the  upper  extremities,  without  any  spinal  tenderness 
in  the  commencement ;  but  when  the  disease  had  lasted  for  some  time. 


506  CLINICAL   MEDICINE. 

the  affection  seemed  to  spread  towards  the  spinal  column.  When  this 
took  place  it  generally  caused  an  aggravation  of  the  disease ;  but  it  is 
no  less  true,  that  we  had  many  instances  where  it  could  not  be  disco- 
vered ;  and  you  are  not  to  think  that  this  irritation  of  the  spinal  cord 
should  always  precede  the  paralytic  affection  of  the  wrist  and  hand, 
which  is  observed  in  painter's  colic.  You  have  seen  in  this  hospital 
two  cases  of  spinal  tenderness  supervening  on  peritonitis  and  acute 
gastric  irritation,  and,  in  fact,  in  every  disease  in  which  the  nervous 
extremities,  w^hich  are  distributed  to  the  parietes,  or  viscera  of  the  ab- 
domen are  engaged,  you  find  almost  invariably  that,  after  some  time, 
there  will  be  pain  and  tenderness  of  the  spinal  column  as  the  conse- 
quence of  these  diseases.  On  the  other  hand,  I  grant,  that  as  soon 
as  the  spine  becomes  affected,  w4iether  the  disease  be  tympanitis,  peri- 
tonitis, or  that  swelling  of  the  belly  to  which  the  name  of  hysterical 
meteorism  is  applied,  there  will  be  certainly  an  aggravation  of  the  ex- 
isting symptoms. 

You  perceive  this  conducts  us  to  the  solution  of  the  question,  how  far, 
in  the  treatment  of  chronic  complaints,  are  we  to  consider  spinal  neu- 
ralgia as  the  cause  or  consequence  of  the  disease.  Sometimes  those 
troublesome  hysterical  affections,  which  you  are  called  on  to  treat,  are 
preceded  by  spinal  neuralgia,  but  in  many  well-marked  cases  it  is  totally 
absent.  I  wish  to  call  your  attention  to  this  subject,  because  medical 
men  have  been  biassed,  to  a  very  considerable  extent,  by  the  statements 
made  by  Mr.  Teale,  and  others,  respecting  the  treatment  of  various 
anomalous  affections,  supposed  to  be  connected  with  irritation  in  the 
spinal  column.  Every  female  who  complains  of  any  kind  of  abdominal 
or  pectoral  symptoms  of  an  obscure  nature  is  examined  all  over  the 
spine,  and  if  the  slightest  tenderness  be  detected,  according  to  the  prac- 
tice generally  pursued,  you  are  to  leech  and  blister  her  back,  or  to  ap- 
ply tartar  emetic  ointment. 

I  think  I  have  seen  injurious  effects  from  this  plan  of  treament.  In- 
quire carefully  into  the  history  of  the  case,  and  ascertain,  if  possible, 
whether  it  was  the  central  or  circumferential  parts  which  were  first 
affected,  for,  in  the  latter  case,  you  can  promise  yourselves  less  from  any 
local  application  to  the  spine  than  in  the  former;  whereas,  in  those 
instances  where  the  disease  has  travelled  from  the  centre  to  the  circum- 
ference, you  may  hope  for  success  from  local  applications.  It  is  impor- 
tant to  recollect,  gentlemen,  that  violent  enteritic  affections  may  pro- 
duce paralysis  of  the  lower  extremities.  In  the  case  of  a  young  gentle- 
man, whose  disease  arose  from  obstruction  in  consequence  of  eating 
nuts — and  to  which  I  shall  advert  in  a  future  lecture,  violent  enteritis 
and  peritonitis  arose,  and  he  had  two  relapses  ;  from  these  he  recovered 


PATHOLOGY    OF    NERVOUS    DISEASES.  507 

with  difficulty^  but  they  left  him  paralytic  of  his  lower  extremities. 
After  two  months,  the  paralysis  speedily  yielded  to  the  application  of 
stimulating  liniments.  This  case  Mr.  Kirby  and  Mr.  Cusack  saw.  In 
another  remarkable  case,  concerning  which  I  was  consulted  by  Dr.  Ire- 
land, a  frequently  recurring  vomiting  was  in  the  end  followed  by  para- 
lysis of  the  lower  extremities. 

What  I  wish  to  impress  upon  your  attention  is,  that  pain,  numbness, 
spasm,  and  loss  of  power  from  an  affection  of  the  circumferential  parts 
of  the  nerves,  may  commence  in  these  extremities,  and  be  propagated 
towards  the  centre,  so  as  to  be  finally  confounded  with  diseases  origi- 
nating in  the  central  parts  themselves.  You  have  seen  in  the  patient, 
James  Moore,  hemiplegia,  which  I  am  convinced  had  its  origin  in  the 
extremities.  Have  you  not  also  seen,  in  the  cases  of  peritonitis,  gastric 
irritation,  and  painter^s  colic,  a  consecutive  affection  of  the  spine  ?  In- 
deed, it  frequently  happens,  that  paralysis,  commencing  in  the  nervous 
extremities,  may  not  only  induce  disease  of  the  spine,  but  in  time  bring 
on  disease  of  the  brain  itself.  It  does  not  follow  that  a  fatal  paralysis 
affecting  the  brain  should  commence  in  that  organ.  In  Dr.  Woolaston's 
case,  are  we  to  account  for  the  occasional  partial  amaurosis  under  which 
he  laboured,  for  such  a  length  of  time  before  his  death,  by  referring  it 
to  disease  of  the  brain  ?  In  consequence  of  a  temporary  paralysis  of 
one  half  of  the  retina  of  each  side,  he  saw  but  the  halves  of  objects,  and 
from  this  he  argued,  that  there  was  a  semi-decussation  of  the  optic 
nerves.  This  happened  several  times,  but  never  remained  any  length 
of  time,  and  I  do  not  tliink  that  at  that  period  it  was  proved  that  any 
disease  existed  in  the  brain. 

Some  time  back,  I  saw,  with  Dr.  Brereton,  a  very  singular  example 
of  defective  vision  in  a  wealthy  bookseller,  who  had  lost  the  sight  of 
one  eye  from  accident.  This  gentleman,  one  day,  in  going  up  a  hiU 
near  Clonskeagh,  remarked,  that  where  there  v»^as  but  one  man,  he  saw 
two  men,  but  divided  at  the  middle,  as  if  they  were  cut  by  a  vertical 
Hue  into  two  halves.  I  questioned  him  closely  on  the  occurrence, 
thinking  it  to  be  the  effect  of  imagination,  but  he  said  this  was  not  the 
case,  and  that  he  was  perfectly  convinced  he  saw  double.  This  is  but 
one  way  of  accounting  for  tliis  optical  delusion.  It  is  well  known  that 
when  vision  is  much  impaired,  the  power  of  seeing  light  often  remains, 
when  the  eye  cannot  distinguish  any  particular  object.  A  partial  and 
temporary  paralysis  of  the  retina,  in  a  vertical  section,  may  have  given 
rise  to  an  apparent  white. line,  bisecting  the  object  vertically.  Again; 
in  the  case  of  a  fine  young  lady,  whom  I  saw  along  with  Dr.  Beatty, 
amaurosis,  acute,  sudden,  and  complete,  came  on  without  any  headache 
or  cerebral  symptoms  being  complained  of.     When  called  on  to  see  her, 


508  CLINICAL   MEDICINE. 

I  found  her  walking  about  the  drawing-room,  quite  cheerful,  and  enjoy- 
ing a  good  appetite,  but  perfectly  bhnd.  After  the  lapse  of  some  days, 
these  symptoms  were  followed  by  profound  coma  and  death. 

But  there  are  other  instances  more  decidedly  corroborative  of  the 
positions  I  have  laid  down.  You  all  know  that  if  a  man  gets  a  blow  or 
cut  on  the  forehead,  which  wounds  or  divides  the  frontal  nerve,  not  only 
the  parts  which  that  nerve  supplies  become  paralytic,  but  that  also  the 
diseased  impression,  thus  produced,  spreads  towards  the  centre,  affects 
those  nerves  which  anastomose  with  the  frontal,  and^  by  means  of  the 
communication  formed  between  the  nerves  of  the  eye-ball,  through 
the  lenticular  ganglion,  deranges  the  functions  of  the  optic  nerve 
and  causes  amaurosis,  formerly  I  was  in  the  habit  of  giving  a  diffe- 
rent account  of  this,  and  thought,  that  because,  in  some  of  the  lower 
classes  of  animals,  as  for  instance  the  mole,  the  fifth  nerve,  from  which 
the  frontal  is  derived,  is  the  true  nerve  of  vision — those  animals  having 
no  optic  nerve"^,  I  had  found  an  analogy  capable  of  giving  an  explana- 
tion of  the  fact,  that  injury  of  the  frontal  nerve  is  sometimes  followed 
by  blindness.  But  this,  I  am  of  opinion,  cannot  be  the  true  mode  of 
accounting  for  the  amaurosis,  as  I  can  now  readily  conceive  how  injury 
of  any  other  nerve,  having  communication  with  the  optic,  may  spread 
inwards,  and  finally  derange  or  destroy  its  functions. 

You  will  frequently  observe  persons  in  the  decline  of  life,  who  other- 
wise enjoy  tolerable  health,  exhibiting,  as  it  were,  a  slight  shade  of 
paralytic  affection  of  the  system,  fitful  and  capricious  in  its  appearance 
and  duration,  sometimes  remarkable  on  every  instance  of  corporeal 
exertion,  sometimes  scarcely  at  all,  presenting  at  one  time  a  reiteration 
of  successive  attacks,  and  at  another  time  being  totally  absent  for 
months.  Some  cases  of  this  kind  I  have  studied  for  months,  and  one 
in  particular  for  years.  The  gentleman,  who  was  the  subject  of  the 
latter,  complained  of  barely  perceptible  weakness,  and  dragging  of  one 
of  his  legs  whenever  he  was  tired ;  but  if  he  took  a  glass  of  wine  on 
coming  home,  he  got  quite  well,  and  these  symptoms  disappeared. 
Matters  went  on  this  way  for  a  considerable  length  of  time,  the  para- 
lysis being  at  one  time  in  one  leg  and  then  in  the  other.  At  last  he 
got  a  paralytic  stroke,  which  lasted  for  some  time  and  then  subsided. 

•  A  curious  instance  of  the  total  absence,  or  imperfection,  of  a  pair  of  nerves,  is  related 
by  the  Rev.  Mr.  Bree,  in  the  Magazine  of  General  History  : — "  A  white  cat,  of  the  Per- 
sian breed  was  kept  in  his  family  as  a  favourite.  The  animal  was  a  female,  quite  white 
and  perfectly  deaf.  She  produced,  at  various  times,  many  litters  of  kittens,  of  which  some 
were  quite  white,  others  more  or  less  mottled,  tabby,  &c.,  &c.  But  the  extraordinary  cir- 
cumstance is,  that  of  the  offspring  produced  at  one  and  the  same  birth,  such  as  were,  like 
the  mother,  entirely  white,  were,  like  her,  invariably  deaf ;  while  those  that  had  the  least 
speck  of  colour  on  their  fur,  as  invariably  possessed  the  usual  faculty  of  hearing." 


i 


PATHOLOGY    OF    NERVOUS    DISEASES.  509 

lie  next  got  confirmed  paralysis  of  one  side,  and,  soon  after  this,  was 
carried  off  by  an  attack  on  the  brain. 

You  will  often  find  persons  similarly  affected  with  paralytic  attacks 
of  the  extremities,  at  first  slight  and  transient,  but  afterwards  increas- 
ing in  vigour  and  intensity,  until  they  terminate  in  ramollissement  or 
eff'usion.  Formerly  I  was  of  opinion,  that  this  fugitive  and  shifting 
paralysis  depended  upon  local  congestion  in  the  brain,  and  others  have 
attributed  it  to  efl'usion,  but  tliis  is  not  the  fact.  Persons  may  die 
after  having  laboured  for  some  time  under  hemiplegia,  and  yet  no 
trace  of  lesion  of  the  cerebral  mass  be  detected  :  and  w^hy  ?  Because 
many  of  them  are  cases  of  this  creeping  paralysis,  comm.encing  in  the 
peripheral  extremities,  and  travelling  gradually  towards  the  centres  of 
the  nervous  system. 

It  is  only  on  the  principle  of  there  being  such  a  disease  as  local  para- 
lysis not  induced  by  lesions  of  the  nervous  centres,  that  we  explain  the 
origin  and  nature  of  such  cases  as  paralysis  of  the  deltoid,  concerning 
which  Dr.  EUiotson  has  made  so  many  interesting  observations.  It  is 
hy  reference  to  this  hypothesis  alone,  that  we  ca7i  account  for  the  follow- 
ing cases,  detailed  by  Dr.  Cooke,  in  his  admirable  work  on  palsy : — 

"  I  have  lately  had  an  opportunity  of  seeing  a  case  of  anomalous 
hemiplegia  attended  with  circumstances  not  less  extraordinary  than  those 
above  described.  An  officer  of  high  rank  in  the  army,  who  is  now 
about  sixty  years  of  age,  was,  in  the  year  1795,  affected  with  a  dimi- 
nution of  power  in  the  right  hand.  This  complaint  increased,  notwith- 
standing a  variety  of  modes  of  treatment,  till  the  year  1800,  when, 
after  a  course  of  mercury,  recommended  by  Mr.  Cline,  its  further  pro- 
gress was  stopped,  since  which  time  the  disease  has  remained  stationary. 
The  peculiar  circumstances  of  this  case  are  the  following.  The  muscles 
of  the  left  arm,  from  the  shoulder  to  the  elbow,  are  much  wasted,  and 
greatly  diminished  in  power ;  while  the  muscles  of  the  fore-arm  are 
not  at  all  lessened  in  size,  and  but  little  in  power.  The  state  of  the 
right  side  is  just  the  reverse,  the  muscles  of  the  upper  arm  being  of 
their  natural  size,  and  possessing  their  full  power ;  whilst  those  of  the 
fore-arm  are  very  much  wasted,  and  their  motion,  especially  that  of  the 
fingers,  is  almost  entirely  abolished.  In  all  other  respects,  this  gentle- 
man appears  to  be  perfectly  well.  No  cause  for  this  disease  can  be 
assigned,  nor  did  any  method  of  treatment  afford  the  smallest  rehef, 
till  the  mercurial  course  was  adopted,  when  the  progress  of  the  disorder 
was  arrested  in  the  year  above-mentioned.  Since  that  time  no  attempts 
to  remove  the  complaint  have  been  made,  yet  it  does  not  increase. 

"In  a  late  publication  by  Mons.  Keratry,  a  case  of  general  palsy  is  re- 
lated, the  circumstances  of  which  are  very  extraordinary.     This  case  is 


510  CLINICAL   MEDICINE. 

adduced  with  a  view  of  showing  how  little  residue  of  animal  existence 
is  sufficient  for  the  preservation  of  the  intelligent  being.  There  is  now 
living,  he  says,  in  D'Isle  et  Yilaine,  a  person,  who,  after  having  been 
blind  for  ten  years,  lost  also  the  sense  of  hearing,  and,  in  a  little  time 
afterwards,  became  almost  universally  paralytic.  He  was  entirely  deprived 
of  the  use  of  his  arms,  legs,  thighs,  and  of  the  whole  exterior  surface  of 
the  body,  with  the  exception  of  a  part  of  the  face ;  but  the  power  of 
speech,  and  the  functions  of  respiration,  circulation,  and  digestion  re- 
mained. Under  these  deplorable  circumstances,  however,  he  is  not, 
says  Mons.  Keratry,  wholly  without  consolation,  for  a  sort  of  intercourse 
is  preserved  with  his  family  and  friends,  by  means  of  characters  traced 
on  that  part  which  still  retains  its  sensibility,  and  in  this  state  of  unex- 
ampled misery,  he  retains,  in  some  degree,  the  distinguishing  character 
of  man — intelligence.^^ 

I  saw,  with  Sir  Philip  Crampton,  a  case  of  paralysis,  in  which  the 
mouth  was  drawn  upwards  and  to  one  side,  accompanied  by  ptosis  of 
the  upper  eyelid  of  the  same  side,  so  as  to  produce  very  great  distortion. 
Sir  Philip  Crampton,  with  his  usual  decision,  said,  "  put  a  blister  here 
and  there,  here  and  then  there,  and  you  set  things  to  rights,^^  marking 
out,  at  the  same  time,  a  space  over  each  of  the  principal  trunks  of  the 
iBfth  nerve,  which  are  expanded  over  the  side  of  the  face.  It  happened 
exactly  as  he  predicted ;  the  first  blister  we  applied  pulled  up  the  eye- 
lid, the  next  partially  rectified  the  distortion  of  the  mouth,  and  the 
third  made  it  quite  straight.  Now,  the  phenomena  of  this  case  and  its 
treatment  cannot  be  explained  by  supposing  the  paralysis  to  arise  from 
disease  of  the  brain ;  but  if,  on  the  other  hand,  you  consider  the  disease 
as  originating  in  the  nervous  extremities  themselves,  how  easy  will  it  be 
to  account  for  the  mode  of  operation. 

The  paralysis  of  the  insane,  first  described  by  Esquirol,  and  spoken  of 
by  Andral,  in  his  admirable  lectures  on  monomonia,  offers  another  in- 
stance of  creeping  paralysis,  of  palsy  travelling  from  the  circumference 
towards  the  centre."^ 

This  disease  is  most  common  in  that  species  of  derangement  termed 
idiotcy,  and  it  has  been  remarked,  that  those  whose  insanity  was  caused 

*  I  think  it  is  quite  evident,  that  many  of  the  cases  described  by  Rostan,  as  examples 
of  creeping  palsy,  caused  by  ramoUissement  of  the  brain,  should  rather  be  considered  as 
cases  of  disease  spreading  from  the  extremities  of  the  nervous  system  to  the  centre.  The 
case  of  the  old  woman,  named  Dassonville,  related  by  Rostan,  was  clearly  of  this  nature. 
She  had,  for  a  year,  experienced  sensations  of  numbness  in  the  lower  extremities,  and  a 
slight  diminution  in  their  muscular  power,  so  as  to  cause  her  gait  to  resemble  a  dragging 
of  her  legs  rather  than  walking ;  during  this  period,  too,  her  mind  was  a  little  impaired 
and  weakened.  This  series  of  symptoms  was  closed  by  evident  inflammation  of  the  brain, 
ending  in  coma.  I  cannot  but  consider  Rostan  in  error  when  he  attributes  the  former 
symptoms  as  produced  by  the  same  cause  as  the  latter. 


PATHOLOGY    OF    NERVOUS    DISEASES.  511 

by  venereal  excesses,  whether  males  or  females,  by  sexual  connexion 
or  by  masturbation,  and  those  in  whom  it  was  occasioned  by  habits  of 
intoxication,  were  the  most  hable  to  this  disease.  M.  Esquirol  also 
believes,  that  it  is  a  peculiar  consequence  of  the  abuse  of  mercury. 

When  we  recollect  that  in  idiotcy  there  is  no  vascular  excitement, 
no  paroxysms  of  violence,  no  determination  of  blood  to  the  head,  and 
no  head-ache,  we  must  allow  that  this  species  of  paralysis  is  of  most 
frequent  occurrence  in  that  variety  of  mental  ahenation,  which  is  least 
likely  to  be  produced  by  a  local  disease  in  the  nervous  centres,  capable 
of  giving  rise  to  a  paralytic  affection  of  the  circumferential  parts. 
When  we  accurately  examine  the  march  and  progress  of  this  paralysis, 
we  find  it  attended  with  many  circumstances  clearly  denoting  its  origin 
in  the  nervous  extremities,  notwithstanding  what  some  French  patho- 
logists have  asserted  to  the  contrary  ; — the  slow  manner  in  which  it 
creeps  from  one  part  to  another ;  the  fact  that,  after  the  disease  has 
occasioned  an  almost  complete  loss  of  power  in  the  lower  extremities, 
the  weakness  may,  on  some  days  or  hours,  be  less  remarkable,  or  even 
disappear  altogether ;  so  effectually,  indeed,  that  if,  for  experiment,  you 
endeavour  to  throw  the  patient  down,  he  will  give  very  powerful  resist- 
ence.  In  this  circumstance,  says  Andral,  emphatically,  we  find  the 
proof  of  the  absence  of  any  organic  lesion. 

Another  proof  of  its  not  depending  on  any  lesion  of  the  nervous 
centres  is  derived  from  the  very  extent  to  which  it  may  arrive,  for,  in 
the  third  stage  of  the  disease,  the  paralysis  is  complete  and  general,  in- 
cluding the  four  limbs,  the  tongue,  and  the  voluntary  muscles  of  the 
trunk.  The  involuntary  muscles  too,  especially  those  connected  with 
the  respiratory  movements,  become  influenced ;  in  this  third  and  highest 
degree  of  the  paralysis,  convulsive  movements  may  also  occur,  present- 
ing the  strange  phenomena  of  the  alternate  paralysis,  and  the  complete 
contractility  of  the  same  voluntary  and  involuntary  muscles,  and  of  a 
voluntary  muscle,  which  is  perfectly  disobedient  to  the  will,  being 
thrown  into  bizarre  and  unwonted  motion  by  the  involuntary  impulse. 
This  fact,  gentlemen,  is  in  itself  sufficient  to  prove  the  truth  of  the  pro- 
position I  have  advanced,  that  a  morbid  state  of  the  nervous  extremities, 
is  often  unconnected  with,  and  independent  of,  any  central  lesion. 

In  my  own  practice,  cases  of  creeping  paralysis,  corroborating  this 
conclusion,  have  occurred.  Thus  I  saw,  in  consultation  with  Mr. 
CoUis,  a  clergyman,  all  of  whose  extremities  had  gradually  become 
afi'ected  with  the  shghtest  possible  degree  of  paralysis,  affecting  both 
the  motion  and  sensation,  the  latter  rather  more  than  the  former.  The 
progress  of  the  disease  was  so  irregular  and  gradual,  it  is  so  variable, 
and  has  now  lasted  so  long,  without  any  further  increase  in  it's  intensity, 


512  CLINICAL   MEDICINE. 

that  both  Mr.  CoUis  and  myself  have  little  doubt  that  the  disease  is 
unconnected  with  any  lesion  of  the  brain  or  spinal  marrow. 

In  the  following  interesting  case  the  paralysis  is  also  evidently  inde- 
pendent of  any  alteration  in  the  nervous  centres  : — Dr.  Knaggs  of 
Mountrath  had  a  very  severe  and  prolonged  attack  of  the  late  epidemic 
fever  in  the  month  of  March,  1848 ;  his  life  was  much  endangered, 
his  head  being  engaged  throughout,  but  he  had  no  apoplectic  nor  con- 
vulsive fit.  On  recovery  he  found  that  he  had  almost  entirely  lost 
sensation  in  the  ring  and  little  fingers  of  the  left  hand,  but  the 
power  of  motion  was  complete :  while  in  the  forefinger  of  the  same 
hand  there  was  paralysis  of  motion ;  but  sensation  was  perfect.  This 
state  continuing,  he  came  to  town  a  month  afterwards  to  consult  me-— 
when  I  saw  him  with  Dr.  Neligan,  the  paralysis  of  sensation  and  of 
motion  was  just  as  when  he  first  experienced  it,  but  he  thought  that  he 
had  less  power  in  performing  any  delicate  manipulation  with  the  fore- 
finger, and  there  was  very  great  atrophy  of  aU  the  special  muscles  of 
this  finger,  while  the  other  muscles  of  the  hand  and  arm,  including 
those  of  the  ring  and  little  fingers,  were  not  in  the  least  wasted :  thus 
affording  a  beautiful  illustration  of  the  intimate  connexion  which  exists 
between  the  motive  power  and  nutrition. 

Before  concluding  this  summary  of  my  views  on  some  points  con- 
nected with  the  pathology  of  the  nervous  system,  which  I  published 
for  the  first  time  many  years  since,  and  of  the  truth  of  which  subse- 
quent experience  has  fully  convinced  me,  I  cannot  avoid  expressing  my 
surprise  that.  Dr.  Todd — in  his  admirable  essay  on  the  Physiology  of 
the  Nervous  System,  published  in  the  Cyclopsedia  of  Anatomy — has  not 
noticed  my  observations,  although  it  is  evident  from  the  following 
paragraph  among  others,  that  he  has  arrived  at  the  same  conclusion: — 
"  I  shall  here  cite  various  facts,  in  addition  to  those  already  adduced, 
which  unequivocally  demonstrate,  that  a  power  exists  in  the  cord  of 
exciting  movements  in  parts  which  receive  nerves  from  it,  by  changes 
occurring  in  its  substance,  which  may  arise  there  from  some  modifica- 
tion of  its  nutrition  developed  in  the  cord  itself,  or  he  excited  hy  a 
stimulus  brought  to  act  upon  it  hy  afferent  or  sensitive  nerves!' 


i 


.13 


LECTURE  XXXIV. 

APOPLEXY. PATHOLOGY   OP    CEREBRAL   DISEASES. 

Gentlemen, — Two  persons  labouring  under  severe  cerebral  disease, 
admitted  lately  into  the  same  ward,  presented  a  striking  contrast  be- 
tween the  symptoms  by  which  each  respectively  was  accompanied ;  in 
fact,  so  completely  did  these  cases  differ  in  their  duration  and  history, 
that  they  scarcely  resembled  each  other  in  anything  but  their  fatal  ter- 
mination j  and  it  was  consequently  expected  by  all  who  had  watched 
their  progress  during  life,  that  an  examination  of  the  brain  would  de- 
tect lesions  of  that  organ  as  different  in  their  nature  as  had  been  the 
symptoms  wliich  they  had  occasioned. 

Such,  I  confess,  was  my  own  opinion,  and  such  was  the  opinion  of 
many  others  who  have  no  little  experience  in  pathology.  The  result, 
however,  differed  widely  from  our  expectations,  and,  is  therefore,  well 
worthy  of  your  attention. 

As  this  result  is  in  direct  opposition  to  our  preconceived  opinions 
concerning  the  origin  and  causes  of  some  of  the  most  serious  derange- 
ments of  the  cerebro-spinal  functions,  I  must  trespass  on  your  patience 
while  I  lay  before  you  the  particulars  of  these  cases,  and  the  lesions 
observed  on  dissection ;  after  which  we  shall  compare  them  together, 
and  consider  what  pathological  and  practical  inferences  may  be  drawn 
from  them.  I  am  the  more  anxious  to  draw  your  attention  to  this  sub- 
ject, because  many  late  writers  on  diseases  of  the  brain  affect  an  accu- 
racy of  diagnosis  which  I  have  found  unattainable  in  my  practice. 
Numerous  cases,  it  is  true,  are  cited  by  each  of  these  authors,  and  are 
so  arranged  and  classified  that  the  conclusions  seem  to  be  arrived  at  by 
a  perfectly  fair  induction,  and  of  course  command  our  assent,  on  the 
strongest  grounds,  the  evidence  of  facts.  It  is  to  be  feared,  however, 
that  these  facts  have  been  too  frequently  warped  to  suit  preconceived 
pathological  arrangements,  apparently  founded  on  the  basis  of  morbid 
anatomy ;  and  I  am  inclined  to  think  that  a  more  unbiassed  observer 
VOL.  I.  33 


514  CLINICAL  MEDICINE. 

will  find  little  cause  to  join  the  ranks  of  those  who  claim  for  this  de- 
partment of  medical  science  a  degree  of  accuracy  almost  equal  to  that 
which  the  unrivalled  discoveries  of  Laennec  have  enabled  us  to  attain 
in  the  diagnosis  of  pectoral  affections.  To  prevent  the  suspicion  of 
having  accommodated  the  history  of  these  cases  to  any  opinion  of  my 
own^  I  shall  read  them  out  from  the  case-book. 

Patrick  Kearney,  aged  40,  admitted  October  6th. — Has  always  en- 
joyed good  health,  with  the  exception  of  being  subject  occasionally  to 
ill-conditioned  ulcers.  Three  months  ago,  after  having  been  subject  to 
very  violent  vertigo  for  some  time,  he  was  attacked  by  slight  hemiplegia 
of  the  left  side,  from  which  he  recovered  in  three  days.  The  vertigo, 
however,  continued,  and  in  walking,  he  consequently  frequently  stag- 
gered, and  sometimes  fell,  but  did  not  become  insensible ;  and  on  such 
occasions,  he  was  able  immediately  to  rise  from  the  ground  without 
assistance.  Three  weeks  ago  he  again  lost  the  use  of  his  left  side  in 
the  evening,  and  says  that  this  attack  was  not  preceded  by  head-ache. 
His  left  arm  has  lost  the  power  of  motion,  but  not  of  sensation.  The 
forearm  is  flexed  on  the  arm,  the  fingers  on  the  hand,  while  the  latter 
is  bent  towards  the  forearm.  Extension  of  these  parts  could  not  be 
effected  even  by  the  application  of  considerable  force,  and  every  such 
attempt  appeared  to  give  him  pain.  This  flexed  state  seemed  to  arise 
from  a  permanent  tonic  spasm  affecting  the  flexor  muscles  of  these 
parts ;  and  it  is  remarkable  that  it  continued  even  when  the  patient 
was  asleep.  He  has  occasionally  great  trembling  in  this  limb,  but  no 
pain.  The  left  lower  extremity  is  less  engaged ;  there  is  no  flexure, 
and  but  little  trembling.  Pulse  92,  full  and  soft;  other  functions 
natural. 

His  disease  underwent  no  material  alteration  until  11  o^ clock  in  the 
forenoon  of  the  15th  October,  when  his  respiration  became  suddenly 
stertorous,  and  his  eyes  fixed.  The  stertor  increased,  and  in  about  ten 
minutes  he  became  quite  comatose,  having  lost  all  power  of  sense  and 
motion,  and  his  limbs  were  stiff.  This  fit  lasted  about  half  an  hour, 
and  on  its  subsiding,  he  recovered  his  consciousness  perfectly,  but  his 
voice  was  very  obscure,  and  his  articulation  difficult.  His  whole  frame, 
too,  continued  to  be  agitated  by  a  nervous  restlessness  and  tremor.  In 
the  evening  he  had  another  fit,  which  was  not  so  severe  as  that  of  the 
morning.  During  the  night  he  did  not  sleep  a  moment,  but  constantly 
cried  aloud,  so  as  to  disturb  the  other  patients,  and  was  perpetually 
agitated  and  restless,  making  frequent  attempts  to  leave  his  bed.  At 
8  A.M.  on  the  16th,  the  hemiplegia  was  observed  to  be  increased,  while 
the  tonic  contraction  had  extended  to  the  left  lower  extremity.  During 
the  visit,  a  continued  shivering  affected  him  generally,  but  it  seemed 


J 


APOPLEXY.  515 

greater  on  the  affected  side.  Tliis  rigor  soon  subsided.  Although  so 
agitated  and  restless,  and  although  he  was  constantly  crying  out  in  an 
incoherent  manner,  as  if  from  pain,  yet  when  spoken  to,  he  answered 
in  a  perfectly  rational  manner,  and  said  he  had  no  pain  in  the  head, 
nor  did  he  lose  his  intellect  or  speech  until  the  very  moment  of  his 
death,  which  took  place  about  noon  on  the  same  day.  During  the  time 
which  intervened  between  the  first  fit  and  his  death,  the  pulse  and  heat 
of  skin  are  noticed  to  have  continued  as  before. 

Examination  of  the  Body  18  hours  after  Death. — Cadaveric  stiffness 
inconsiderable ;  contraction  of  the  left  leg  resolved,  that  of  left  arm 
remains  with  considerable  stiffness.  The  vessels  of  the  scalp  contained 
but  little  blood,  but  on  opening  the  cranium,  the  sinuses  of  the  dura 
mater  were  found  much  distended  by  fluid  black  blood.  The  vessels 
of  the  pia  mater  exhibited  an  intense  congestion,  being  everywhere 
distended  with  dark  coloured  blood.  No  blood  was  extravasated  on  the 
upper  surface  of  the  brain,  neither  was  there  anywhere  a  trace  of  sub- 
arachnoid serous  effusion,  or  of  puriform  matter,  coagulable  lymph,  &c. 
At  the  base  of  the  brain,  a  stratum  of  extravasated  blood,  in  some 
parts  very  thin,  but  in  other  places  two  or  three  lines  in  thickness, 
was  found  at  both  sides  of  the  ]pons,  and  occupying  all  the  space  be- 
tween it  and  the  commissure  of  the  optic  nerves ;  coagulated  blood 
also  existed  in  the  fourth  ventricle,  and  passing  by  the  iter^  it  so 
exactly  occupied  the  third,  and  both  lateral  ventricles,  that  when  ex- 
tracted, the  coagula  appeared  like  casts  of  these  cavities.  It  is  to  be 
observed,  however,  that  the  blood  so  effused  into  these  cavities,  by 
no  means  considerably  distended  them. 

A  pretty  accurate  idea  of  its  quantity  in  all  may  be  formed  fom  the 
fact,  that  in  each  of  the  lateral  ventricles  the  coagulum  in  size  and 
shape  resembled  a  leech  of  the  ordinary  size,  when  about  half  fiUed  by 
sucking.  No  rupture  of  the  basilar  or  other  arteries  could  be  found  ; 
but  on  examining  the  structure  of  these  and  the  neighbouring  arteries, 
forming  the  circle  of  Willis,  the  following  diseased  state  of  tlieir  parietes 
was  detected.  The  thickness  of  the  arterial  tunics  was  increased,  and 
the  three  coats  were  separated  from  each  other  by  areolar  tissue,  loose 
and  friable  in  its  texture ;  in  fact,  the  connexion  between  these  coats 
was  but  trifling,  and  with  a  little  care,  the  middle  or  elastic  tunic  could 
be  drawn  out  from  between  the  others  in  the  form  of  a  hollow  cyHnder. 
Between  the  middle  and  internal  tunics  were  several  patches  of  white 
opaque  matter,  but  as  yet  no  ossific  deposition.  A  most  minute  and 
careful  examination  of  the  brain,  cerebellum,  medulla  oblongata,  and 
about  one  inch  of  the  cervical  spinal  marrow,  was  next  made,  but  not 
the  least  morbid  alteration— not  the  least  change  in  consistence  or 


516  CLINICAL   MEDICINE. 

colour — or,  indeed,  in  any  other  particular  from  the  healthy  state,  could 
be  anywhere  detected.     Thoracic  and  abdominal  viscera  healthy. 

Before  I  make  any  remarks  on  this  curious  case,  I  shall  read  you  the 
particulars  observed  during  the  illness  of  Joseph  Murphy. 

This  young  man,  aged  18  years,  was  admitted  on  the  5th  of  Novem- 
ber. He  was  a  shoe-maker's  apprentice,  and  had,  until  the  commence- 
ment of  his  present  illness,  four  weeks  ago,  always  enjoyed  good  health, 
with  the  exception  of  an  incontinence  of  urine,  which  he  attributed  to 
the  cruelty  of  his  master,  who  only  permitted  him  to  leave  his  work  at 
certain  times,  in  consequence  of  which  he  was  unable  to  relieve  his 
bladder,  as  often  as  nature  required.  About  a  month  before  his  admis- 
sion, having  been  much  exposed  to  damp  and  cold  air,  he  observed  his 
abdomen  to  sweU,  and  become  painful  on  motion,  particularly  on  stoop- 
ing. Within  the  last  eight  days  these  symptoms  have  been  much  in- 
creased ;  purging  has  supervened,  and  he  has  been  attacked  by  an  acute 
pain  in  the  left  hypochondrium,  and  such  a  degree  of  debility  that  he  is 
compelled  to  abandon  his  occupation. 

November  6th. — Abdomen  considerably  swollen;  the  swelling  ap- 
peared to  be  rather  the  consequence  of  a  tympanitic  distention  of  the 
intestines  than  of  dropsical  effusion ;  no  part  of  the  abdomen  was  ten- 
der on  pressure  except  the  region  of  the  spleen,  which  was  obviously 
much  enlarged.  He  described  himself  as  affected  with  a  pain  which 
shot  across  the  epigastrium  from  one  hypochrondrium  to  the  other,  and 
rendered  stooping  at  his  work  extremely  distressing.  The  patient  was 
considerably  emaciated ;  appetite  good ;  some  thirst ;  tongue  red  and 
dry ;  bowels  free,  two  or  three  stools  being  passed  daily ;  no  tenesmus  ; 
involuntary  discliarge  of  urine ;  no  pain  or  tenderness  in  the  region  of 
the  bladder;  pulse  120;  sleeps  well;  has  no  pain  in  the  head;  no 
derangement  whatever  of  cerebral  or  respiratory  functions ;  his  eyes 
are  suffused,  but  not  weak  or  sore.  Twenty  leeches  were  applied  to  the 
epigastrium,  and  he  was  put  on  low  diet. 

November  7th. — ^Nurse  states  that  he  continued  without  any  altera- 
tion in  his  symptoms  until  yesterday  evening  after  supper,  when  becom- 
ing very  drowsy,  he  went  to  bed,  and  fell  into  what  she  thought  was  a 
natural  sleep.  This  morning,  however,  she  became  alarmed  at  finding 
that  she  could  not  awake  him.  He  is  now  lying  in  a  state  of  deep  coma, 
and  constantly  tosses  his  head  from  side  to  side  on  the  piUow ;  the  eyes 
are  suffused ;  the  pupils  dilated,  and  totally  insensible  to  light ;  there 
is  slight  strabismus  of  the  riglit  eye.  Skin  warm;  pulse  120,  hard, 
and  somewhat  fuU ;  a  rale  is  audible  in  the  trachea.  A  vein  was  imme- 
diately opened,  but  when  about  three  ounces  of  blood  had  been  taken, 
the  pulse  became  very  weak,  and  he  appeared  so  sunk  that  no  more 


APOPLEXY.  517 

blood  was  drawn.  The  pulse  shortly  after  regained  its  strength^  and 
the  tracheal  rale  ceased.  An  injection  of  several  pints  of  warm  water 
was  carefully  administered  by  means  of  Bead's  syringe,  and  brought 
away  an  enormous  quantity  of  hardened  fseces.  In  two  hours  a  turpen- 
tine injection  was  ordered.  In  the  mean  time  his  head  had  been  shaved, 
and  was  kept  constantly  wet  with  towels  dipped  in  cold  water,  while 
the  actual  cautery  was  applied  to  the  nape  of  the  neck,  and  a  scruple  of 
calomel  was  given,  to  be  followed  in  the  course  of  the  day  by  a  draught 
containing  castor  oil  and  spirits  of  turpentine,  for  the  purpose  of  remov- 
ing or  diminishing  the  tympanitic  state  of  the  belly,  which  still  persisted. 
None  of  these  measures  afforded  him  the  least  relief.  The  draught  was 
no  sooner  swallowed  than  it  was  rejected,  and  the  appHcation  of  the 
cautery  roused  him  but  for  a  few  minutes,  after  which  he  again  became 
comatose.  In  the  evening  he  had  a  severe  fit  of  screaming ;  his  pulse 
rose  to  140,  was  somewhat  full  and  hard ;  and  his  death,  which  took 
place  at  nine  o'clock  that  evening,  about  twenty-six  hours  from  the  first 
appearance  of  the  cerebral  symptoms,  was  preceded  by  two  or  three 
slight  convulsive  fits. 

Dissection  12  kottrs  after  Death. — Head:  There  was  no  congestion 
of  the  vessels  of  the  scalp ;  on  removing  the  calvarium,  the  sinuses  of 
the  dura  mater  were  found  gorged  with  black  blood,  mixed  with  small 
quantities  of  fibrine,  deprived  of  colouring  matter.  No  fluid  was  found 
between  the  visceral  layer  of  the  arachnoid  membrane  and  the  convex 
surface  of  the  brain,  and  not  more  than  a  teaspoonful  at  its  base.  The 
pia  mater  was  excessively  congested,  its  larger  veins  gorged  with  black 
blood,  and  their  smaller  branches,  similarly  distended,  formed  numer- 
ous ramifications  over  that  membrane.  In  the  ventricles  of  the  brain 
was  a  small  quantity  of  serous  fluid,  and  a  little  in  the  third  ventricle, 
but  the  quantity  of  serum  so  effused  was  too  inconsiderable  to  be  con- 
sidered as  a  morbid  product.  The  substance  of  the  brain  and  cere- 
bellum was  perfectly  healthy  in  every  respect.  In  both  this  and  the 
preceding  case  the  brain,  when  cut,  exhibited  numerous  red  points,  but 
not  more  than  are  frequently  seen  on  the  section  of  a  perfectly  healthy 
brain. 

Thorax. — Nothing  remarkable,  except  a  considerable  engorgement  of 
the  posterior  portion  of  both  lungs,  owing  partially  to  cadaveric  gravi- 
tation, and  partially  to  the  efi'ect  of  gravitation  during  the  long  agony 
preceding  death.  This,  from  affording  a  crepitating  rale  before  death 
and  from  its  rendering  the  pendant  portions  of  the  lung  impervious  to 
the  air,  Laennec  has  termed  the  pneumonia  of  the  dying,  a  term  by  no 
means  applicable,  for  pneumonia  renders  the  pulmonary  tissue  imper- 
vious, in  consequence  of  an  exaltation  of  the  vital  powers  of  the  affected 


5 is  CLINICAL   MEDICINE. 

part ;  whereas,  in  the  impervious  pulmonary  tissue  just  spoken  of,  this 
state  arises  from  a  decrease — a  gradual  cessation  of  the  vital  powers, 
which  permits  the  vessels  to  allow  the  blood,  in  obedience  to  physical 
laws,  to  accumulate  in  the  most  depending  part. 

Abdomen. — The  large  intestines  were  flaccid  and  empty,  and  lay  con- 
cealed beneath  the  stomach  and  small  intestines,  both  of  which  were 
excessively  distended  with  air,  and  presented  on  their  serous  surfaces . 
the  appearance  of  intense  venous  congestion;  the  veins,  everywhere 
gorged  with  dark  blood,  were  injected  with  this  fluid  to  their  ultimate 
ramifications.  There  was  a  considerable  congestive  redness  in  the  mu- 
cous membrane  of  the  stomach,  and  that  of  the  small  intestines  was 
throughout  their  whole  extent  of  a  slate  colour,  evidently  produced  by 
its  state  of  sanguineous  engorgement  during  life;  the  most  pendent 
portions  of  the  intestinal  loops  were  red,  and  still  more  congested,  in 
consequence  of  post-mortem  gravitation. 

Having  thus  put  you  in  possession  of  the  symptoms  and  post-mortem 
appearances  observed  in  these  two  cases,  I  shall  now,  gentlemen,  pro- 
ceed to  compare  them  together,  and  afterwards  examine  them  with 
reference  to  the  opinions  expressed  by  writers  on  diseases  of  the  brain. 

In  the  first  place,  no  two  cases  could  possibly  difiPer  from  each  other 
more  than  these  in  their  duration,  general  history,  and  individual  symp- 
toms. In  one,  coma  suddenly  supervened  without  any  previous  warnings 
and  persisted  until  death,  accompanied  by  dilation  of  the  pupils,  and 
insensibility  of  the  retina  to  light.  Here  the  derangement  in  the  sen- 
sorial functions  was  quite  unexpected,  and  there  was  neither  hemiplegia, 
tonic  spasms,  rigors,  nor  successive  fits  of  convulsions,  which  were  the 
very  symptoms  that  in  the  other  case  constituted  the  chief  features  of  the 
disease.  In  the  other  case,  too,  were .  absent  the  uninterrupted  state  of 
coma,  the  contraction  of  the  pupils,  and  the  insensibility  to  light. 
The  state  of  the  mind  in  each  was  strikingly  different ;  in  the  one, 
being  as  it  were  annihilated  from  the  very  commencement,  while  the 
other  patient  answered  questions  rationally  to  the  last.  In  the  old  man 
the  cerebral  affection  had  subsisted  for  several  months ;  in  the  young 
man  it  had  proved  fatal  in  twenty-four  hours. 

Having  formed  a  general  comparison  between  the  symptoms  of  these 
two  cases,  can  we  in  the  lesions  observed  in  the  examination  of  the 
brain,  detect  the  causes  of  the  numerous  and  striking  differences  just 
enumerated  ?  Most  certainly  not,  for  the  morbid  appearances  were 
exactly  the  same  in  both,  if  we  except  the  blood  effused  on  the  base,  and 
in  the  ventricles  of  the  old  man^s  brain.  Arguing  from  the  generally 
received  ideas  concerning  the  effects  of  such  an  effusion  of  blood,  its 
detection  in  these  situations  would  undoubtedly  lead  the  morbid  anato- 


PARALYSIS    FROM    CEREBRAL    DISEASE.  519 

mist  to  conclude — had  the  bodies  of  both  these  patients  been  presented  to 
him  for  examination — that  the  man  in  whose  brain  this  effusion  had 
occurred,  must  during  Hfe,  have  been  much  more  Hkely  than  the  other 
to  present  such  symptoms  as  permanent  coma,  dilatation  of  the  pupils, 
insensibility  of  the  retina  to  light,  &c.  In  fact,  it  is  quite  obvious  that 
the  post-mortem  appearances  would  mislead  him,  and  that  the  history 
of  the  cases  thus  formed  would  be  extremely  incorrect — symptoms  being 
attributed  to  one  which  had  only  been  displayed  by  the  other.  I  do 
not  mean  to  assert  that  morbid  anatomists  have  not  long  ago  observed 
that  coma,  dilatation  of  the  pupils,  &c.,  may  occur  without  effusion,  or 
that  effusion  may  exist  without  having  occasioned  these  very  symptoms. 
Still,  however,  it  cannot  be  denied  that  the  cerebral  mass  and  membranes 
being  found  in  every  other  respect  in  exactly  the  same  state  in  two 
cases,  an  effusion  of  blood  on  the  base  and  in  the  ventricle  of  one  being 
superadded  to  the  appearances  observed  in  the  other,  would  be  con- 
sidered as  constituting  an  important  difference,  increasing  the  proba- 
bility of  the  occurrence  of  coma,  &c.,  during  the  hfe  of  that  patient. 
The  cases  just  related  exhibit  striking  exceptions  to  the  justice  of  such 
a  mode  of  argument. 

Let  us  next,  gentlemen,  compare  these  cases  with  the  opinions  re- 
corded by  authors  concerning  the  lesions  connected  with  certain 
symptoms. 

'No  proposition  seems  more  universally  allowed  by  those  who  profess 
to  reduce  cerebral  diseases  to  a  classification  depending  on  evident  alte- 
rations of  structure,  than  that  paralysis  of  one  side  of  the  body  always 
arises  from  a  local  affection  of  the  opposite  hemisphere  of  the  brain. 
This  affection  may  either  consist  of  an  effusion  of  blood,  a  ramoUisse- 
ment,  or  the  pressure  arising  from  a  tumour,  &c. ;  but  in  all  cases  it  is 
assumed  that  hemiplegia  must  be  attended  with,  and  caused  by  some  such 
local  and  evident  alteration.  On  the  other  hand,  general  paralysis, 
affecting  alike  both  sides  of  the  body  is  caused,  according  to  most 
authors,  by  a  general  derangement  of  the  cerebral  circulation  usually 
called  congestion,  and  believed  to  act  equally  on  both  hemispheres.  The 
latter  species  of  paralysis  may  arise  suddenly,  and  may  be  as  suddenly 
relieved,  as  it  ceases  when,  by  means  of  venesection,  we  succeed  in 
removing  the  congestion  that  produced  it. 

An  unbiassed  attention  to  facts  will,  I  tliink,  prevent  us  from  giving 
our  assent  to  either  of  these  propositions.  In  the  first  place,  we  often, 
in  dissecting  the  brains  of  hemiplegic  patients,  find  both  hemispheres,  so 
far  as  evident  alteration  of  structure,  affected  exactly  in  the  same  way. 
This  was  remarkably  the  case  in  Kearney ;  there  was  no  alteration  in 
one  hemisphere  which  did  not  exist  in  the  other,  and  ^^^i  this  man  had 


520  CLINICAL  MEDICINE. 

complete  paralysis  of  one  side.  It  is  in  vain  to  assert  tliat  some  alter- 
ation of  structure  existed,  but  escaped  our  notice,  unless  it  were  micro- 
scopic, for  both  myself  and  those  who  assisted  in  the  dissection  were  too 
familiar  with  diseased  appearances,  and  too  careful  in  conducting  the 
^examination,  to  allow  any  difference  in  one  hemisphere,  as  compared 
with  the  other,  to  escape  notice.  In  the  next  place,  it  is  by  no  means 
an  unfrequent  occurrence  to  meet  with  patients  who,  being  suddenly 
attacked  with  symptoms  of  general  determination  of  blood  to  the  head — 
such  as  head-ache,  tinnitus  aurium,  vertigo,  are  rendered  for  the  time 
more  or  less  completely  hemiplegic,  and  yet  recover  in  the  course  of  a 
few  minutes  or  hours  the  use  of  the  affected  side  so  suddenly  and  so 
perfectly,  as  to  preclude  the  idea  of  local  lesion,  such  as  could  be  detected 
by  the  scalpel  of  the  anatomist.  Of  this  I  have  seen  several  instances, 
both  in  hospital  and  private  practice,  and  which  I  cannot  reconcile  with 
the  doctrines  laid  down  by  Eostan,  Lallemand,  and  other  authors. 

To  quote  one  of  the  many  examples  I  myself  have  seen  : — A  man 
named  Thomas  Lynch  was  admitted  into  Sir  Patrick  Dun's  Hospital, 
afflicted  with  symptoms  indicative  of  cerebral  disease.  During  his  re- 
sidence in  the  hospital,  he  suffered  four  or  five  attacks  of  hemiplegia,  in 
every  respect  complete,  and  depriving  him  of  the  use  of  his  speech. 
Some  of  these  attacks  lasted  only  fifteen  minutes,  while  the  longest  con- 
tinued about  an  hour  and  a  half :  they  ceased  as  suddenly  as  they  com- 
menced, and  left  no  traces  of  hemiplegia  behind  them. 

The  circumstances  of  this  case  evidently  prevent  us  from  assigning 
each  attack  to  a  separate  effusion  of  blood ;  for  were  it  owing  to  this 
cause,  it  would  be  impossible  to  account  at  once  for  the  sudden  appear- 
ance and  as  sudden  cessation  of  so  extensive  and  complete  a  paralysis. 

Again,  I  have  carefully  watched  the  progress  of  several  cases,  which 
after  months  and  years  have  finally  terminated  in  hemiplegia,  the  super- 
vention of  which  I  had  anticipated  from  the  patients  having  remarked  to 
me,  that,  although  otherwise  in  good  health,  they  had  more  than  once 
observed,  when  fatigued  by  exercise,  that  they  felt  a  degree  of  weakness 
in  one  leg,  the  motion  of  which,  so  long  as  this  feeling  continued,  they 
described  as  slightly  approximating  to  the  dragging  of  a  half  paralysed 
extremity.  In  some  this  feeling  was  accompanied  by  a  scarcely-observ- 
able thickness  of  speech,  and  a  certain  confusion  of  mind,  all  of  which 
subsided  shortly  on  their  taking  rest.  These  persons  usually  complained 
at  the  same  time  of  numbness  in  some  part  of  the  affected  extremity, 
and  which  numbness  not  unfrequently  was  the  sole  symptom  of  these 
transient  warnings.  The  remark  already  made  with  regard  to  Lynches 
case  appHes  more  strongly  here ;  and  since  the  hemiplegia,  when  it  did 
supervene,  always  affected  the  side  in  which  these  premonitory  symptoms 


PARALYSIS   FROM    CEREBRAL   DISEASE.  521 

had  been  felt,  we  can  scarcely  avoid  attributing  both  to  the  operation  of 
causes  the  same  in  nature  but  differing  in  degree. 

Many,  I  am  aware,  would  account  for  the  transient  attacks  by  sup- 
posing that  each  was  preceded  by  a  very  small  effusion  of  blood  in  the 
opposite  hemisphere  of  the  brain,  and  that  the  final  complete  hemiplegia 
was  owing  to  a  similar,  but  more  copious  efiPusion.  I  am  ready  to  admit 
the  truth  of  this  explanation  in  those  cases  where  there  have  been  several 
distinct  attacks  of  paralysis,  difiering  in  intensity,  all  affecting  the  same 
side,  and  all  lasting  several  days,  or  even  weeks,  and  then  gradually  disap- 
pearing. Instances  of  this  kind  are  frequent,  and  in  such  it  is  not  unusual 
to  find  traces  of  those  successive  extravasations  of  blood  which  had  caused 
the  series  of  paralytic  attacks ;  but  the  comparatively  longer  duration, 
and  the  gradual  cessation  of  such  attacks,  sufficiently  distinguish  them 
from  the  affections  above  spoken  of,  and  which  are  too  sudden  in  their 
disappearance  to  admit  of  a  similar  explanation. 

The  manner  in  which  the  arteries  of  the  brain  communicate  together 
renders  it  more  difficult  to  conceive  how  local  determinations  of  blood 
could  occur  in  this  organ.  Still,  however,  such  an  occurrence  is  by  no 
means  impossible ;  and,  did  it  take  place,  it  would  account  for  the  phe- 
nomena observed.  Thus,  were  the  right  side  of  the  brain  to  become 
congested,  a  sudden  attack  of  hemiplegia  of  the  left  side  of  the  body 
would  be  produced  suddenly,  and  would  as  suddenly  subside  on  the  re- 
moval of  that  congestion.  When  the  congestion  is  violent,  and  affects 
the  whole  hemisphere,  the  paralysis  will  afi'ect  the  whole  of  the  opposite 
side,  and  will  be  intense ;  when,  on  the  contrary,  the  congestion  is 
inconsiderable,  or  else  confined  to  particular  portions  of  a  single  hemi- 
sphere, the  paralysis  will  be  in  proportion  less  severe  and  less  extensive. 
This  explanation^  does  not  appear  to  be  inconsistent  with  the  laws 
known  to  regulate  the  circulating  system  in  other  organs,  for  it  is  by  no 
means  unusual  for  the  parts  deriving  their  blood  from  one  common 
artery,  to  display  occasionally  very  different  degrees  of  sanguineous  con- 
gestion, a  ckcumstance  only  explicable  on  what  appears  a  very  tenable 
hypothesis — an  active  participation  on  the  part  of  the  smaller  vessels 
and  capillaries  in  the  process  by  which  every  part  of  the  body  is  supplied 
with  blood. 

Another  mode  of  explaining  the  occurrence  of  such  attacks  as  I  have 
described,  is  to  suppose  that  they  arise  from  a  mere  functional  derange- 
ment, more  or  less  intense,  of  the  whole  or  a  portion  of  one  cerebral 

•  Rostan  has  advanced  this  explanation  under  the  head  of  "  Congestion  cerebrale 
locale ;"  but  he  does  not  attempt  to  account  for  the  manner  in  which  these  local  affections 
are  produced,  nor  does  he  sufficiently  dwell  on  them  as  the  frequent  precursors  of  paralysis 
from  extravasation  on  the  side  of  the  brain  most  prone  to  these  local  congestions. 


522  CLINICAL    MEDICINE. 

hemisphere.  This  explanation  would  certainly  account  for  the  sudden 
appearance  and  cessation,  as  well  as  for  the  short  duration  of  such  para- 
lytic affections ;  but  I  do  not  feel  inclined  to  adopt  it,  because  they  are 
invariably  accompanied  by  other  symptoms  denoting  determination  to 
the  head ;  and  also,  because  sooner  or  later  they  usually  terminate  in 
actual  extravasation  of  blood  in  the  side  of  the  brain  opposite  to  the 
side  of  the  body  affected  by  these  transitory  attacks.  Whatever  mode 
of  explaining  the  occurrence  of  these  latter  be  adopted,  it  is  important, 
gentlemen,  to  recollect  that  whenever  they  are  observed,  the  medical 
attendant  must  be  on  his  guard — must  warn  the  patient^s  friends  of  his 
future  danger,  and  must  endeavour,  by  the  most  suitable  means,  to  avert 
the  tendency  to  cerebral  congestion,  and  its  consequence,  extravasation. 
It  is  to  be  regretted  that  the  latter  is  too  often  inevitable ;  such  cases, 
in  persons  past  the  prime  of  life,  being  usually  attended  with  an  alteration 
in  the  texture  of  the  arteries  of  the  brain,  disposing  them  to  rupture. 

The  state  of  these  vessels  in  Kearney  was  worthy  of  attention,  as  the 
existence  of  three  coats  or  tunics,  which  some  have  denied  to  the  cere- 
bral arteries,  was  here  demonstrated.  Another  symptom — tonic  spasms 
of  the  atfected  side,  formed  one  of  the  most  remarkable  features  of  this 
poor  man's  disease,  and,  combined  with  the  hemiplegia,  seemed  to  fur- 
nish indisputable  evidence  of  some  local  affection  of  the  opposite  side  of 
the  brain,  and  yet  none  such  was  detected ;  the  congestion  of  the  pia- 
mater  was  intense  on  both  sides,  although  somewhat  greater  on  the  side 
opposite  to  the  paralysis.  The  difference,  however,  was  inconsiderable, 
and  might  have  been  occasioned  by  the  position  of  the  head  shortly  be- 
fore or  after  death.  I  do  not  say  it  was  so,  for  the  position  was  not  ob- 
served, but  I  mention  this  explanation  to  impress  on  your  minds  how 
trifling  was  that  difference.  Here,  then,  is  a  second  instance  of  an  af- 
fection permanently  confined  to  one  side  of  the  body,  without  any  le- 
sion to  account  for  it,  being  found  in  the  opposite  side  of  the  brain, — a 
fact  at  variance  with  the  testimony  of  several  systematic  writers. 

The  tonic  spasm  of  the  paralysed  extremities  requires  notice  in  ano- 
ther point  of  view,  as  constituting  one  of  the  chief  symptoms  character- 
istic of  ramoUissement,  or  at  least  that  state  of  brain  which  finally  ends 
in  softening.  The  absence  of  any  local  cerebral  affection  in  Kearney,  in 
whom  this  operation  had  been  during  life  so  remarkably  developed,  is 
conclusive  in  proving  that  even  its  most  extreme  degree  may  be  excited 
by  some  other  cause.  The  same  remark  applies  to  the  head-ache,  the  tin- 
gUng  and  the  spastic  pains  of  the  affected  limbs,  the  paralysis,  and  in 
fact  to  each  of  the  whole  group  of  symptoms  which  are  said,  when  com- 
bined with  the  tonic  spasm,  to  constitute  indubitable  evidence  of  rcmol- 
nt.     I  do  not  deny,  that  when  associated  together  in  the  order 


PATHOLOGY   OF    CEREBRAL   DISEASES.  523 

described  by  Lallemand  and  Rostaii^  they  afford  very  strong  evidence  of 
that  lesion,  but  this  I  will  assert^  that  I  have  met  with  several  cases  in 
which,  after  a  careful  comparison  of  the  symptoms  with  the  descriptions 
of  these  authors,  I  w^as  induced  to  make  the  diagnosis  of  ramollissement 
with  considerable  confidence,  and  yet,  as  the  result  proved,  erroneously. 
Had  such  mistakes  occurred  in  my  own  practice  only,  I  might  possibly 
have  believed  that  I  had  not  rightly  understood  these  celebrated  patho- 
logists, but  I  have  witnessed  similar  errors  committed  by  others  so 
often  that  I  am  rather  inclined  to  doubt  the  general  applicability  and 
correctness  of  the  rules  laid  down  for  recognising  this  lesion. 

Let  it  not  be  imagined,  however,  that  I  wish  to  throw  doubts  upon 
the  beneficial  influence  of  morbid  anatomy  on  the  diagnosis  and  treat- 
ment of  diseases  of  the  brain, — far  be  from  me  any  such  intention;  my 
object  in  making  these  observations  is  not  to  retard,  but  to  advance,  the 
progress  of  morbid  anatomy,  by  pointing  out  the  errors  of  some  generally 
received  opinions,  and  thus  opening  the  w^ay  for  a  renewed  and  unpre- 
judiced examination  of  the  subject.  It  may,  indeed,  be  a  priori  ex- 
pected, that  of  all  organs,  the  cerebro-spinal  system  must  give  rise  to 
the  greatest  number  of  diseases  which,  without  much  impropriety  of  ex- 
pression, may  be  termed  functional,  being  of  such  a  nature  as  to  be  un- 
accompanied by  sensible  changes  in  the  matter  of  the  diseased  tissue, 
and  consequently  not  entering  within  the  province  of  morbid  anatomy. 
We  all  know  that  tetanus  may  be  artificially  produced  by  irritation  of 
the  spinal  cord,  and  consequently  that  inflammation  reaching  that  part 
often  occasions  this  disease.  So  far  we  obtain  from  morbid  anatomy 
useful  knowledge  concerning  the  nature  and  treatment  of  certain  cases 
of  tetanus ;  but  do  we  advance  or  retard  the  progress  of  this  department 
of  medicine  by  asserting,  that  inflammation  of  the  spinal  cord  exists  in 
every  case  of  tetanus  ?  So  it  is  with  those  who,  affecting  to  account  for 
all  cerebral  diseases  by  lesions  observed  after  death,  have  excited  ex- 
pectations in  the  student,  which,  not  being  in  every  case  fulfilled, 
he  is  tempted  in  disgust,  to  abandon  all  further  investigations  on  the 
subject. 

No  other  organ  of  the  body,  in  the  healthy  discharge  of  its  func- 
tions, presents  such  opposite  states  as  the  brain  during  the  period  of 
being  awake  and  asleep,  and  yet  we  may  reasonably  doubt  whether 
these  states  are  accompanied  by  any  physical  change  in  the  brain,  or  its 
appendages,  of  sufficient  magnitude  to  be  within  the  cognizance  of  our 
senses. 

Can  we  perceive  any  physical  alteration  in  the  cerebro-spinal  system 
of  an  animal  suddenly  killed  by  prussic  acid,  or  by  violent  concussion  ? 
and  yet,  both  these  undoubtedly  act  on  the  nervous  system, ' 


524  CLINICAL   MEDICINE. 

Nothing  proves  in  a  more  convincing  manner  that  morbid  anatomy 
cannot  be  expected  to  reveal  the  nature  of  all  cerebral  diseases,  as  has 
been  too  implicity  taught  by  many  Trench  pathologists,  than  its  being 
totally  incapable  of  suggesting  or  explaining  the  action  of  some  of  our 
most  useful  remedies.  Thus,  what  are  the  physical  conditions  of  the 
brain  in  delirium  which  indicate,  if  known,  the  exhibition  of  opium  ? 
or,  in  other  words,  why  does  this  medicine  act  so  much  more  benefi- 
cially in  delirium  tremens  than  in  other  species  of  delirium  ?  What 
physical  change  does  the  nervous  mass  undergo  in  cJiorea  sancti  Viti, 
which  would  lead  us  to  expect  such  decided  advantage  from  the  car- 
bonate of  iron  ?  What  alteration  of  nervous  structure  would  induce 
us  to  try  the  effects  of  arsenic  in  certain  cases  of  neuralgia,  or  of 
strychnia  in  paralysis  from  lead  ?  Would  the  inspection  of  the  brain  of 
a  person  labouring  under  sea-sickness,  of  itself  be  sufficient  to  prove 
that  the  oidy  certain  method  of  checking  this  vomiting  is  to  replace  the 
patient  on  terra  firma?  All  these  considerations,  gentlemen,  leave  no 
doubt  on  my  mind  that  the  ancients  were  not  so  wrong  as  Eostan  and 
others  would  have  us  believe,  in  thinking  that  many  nervous  diseases 
were  unattended  with  appreciable  organic  changes  in  the  nerves,  or 
nervous  centres. 

The  object  of  morbid  anatomy,  therefore,  should  be,  not  to  explain 
the  causes  of  cerebral  diseases,  but  to  investigate  and  ascertain  in  what 
number  of  such  diseases  we  may  with  confidence  refer  the  origin  of  the 
symptom  to  evident  lesions.  I  fear  much  that  modern  authors  have 
not  sufficiently  attended  to  this  distinction,  and,  consequently,  have 
most  injudiciously  endeavoured  to  establish  systems,  embracing  aU  the 
various  diseases  of  the  brain  and  spinal  marrow,  on  the  basis  of  morbid 
anatomy,  a  mode  of  proceeding  injurious  to  the  latter  science,  and 
little  calculated  to  promote  the  interests  of  practical  medicine.  If  other 
proofs  of  the  truth  of  this  assertion  were  wanting,  I  might  appeal  to 
the  almost  endless  opinions  lately  published  concerning  the  physical 
alterations  of  the  brain  supposed  to  produce  insanity  and  its  attendant 
diseases ;  opinions  apparently  supported  by  numerous  dissections,  but 
really  too  often  resting  upon  the  supposed  existence  of  morbid  appear- 
ances, which  are  sought  for  with  such  avidity  that  they  are  always  found  ! 

The  following  case  is  another  good  example  of  the  truth  of  the  doc- 
trine I  have  been  now  trying  to  enforce.  It  was  one,  in  which  very 
long-continued  epilepsy  existed  without  any  appreciable  lesion  of  the 
brain  or  spinal  marrow. — Mr.  A.  B.,  the  subject  of  the  case,  was 
visited  during  his  long  illness  by  a  great  many  medical  men ;  among 
the  rest  by  Mr.  CoUes,  Sir  P.  Crampton,  Mr.  Smyly,  Dr.  Lees,  and 
myself.     He  died  on  the  27th  December,  1839,  aged  30  years. 


EPILEPSY   WITHOUT   ORGANIC   DISEASE   OF   THE  BRAIN.  525 

He  had  been  a  very  fine,  robust,  and  intelb'gent  boy,  until  be  was 
nine  years  old,  when  he  unfortunately  got  possession  of  five  or  six  hard, 
unripe  pears,  and  devoured  them  greedily :  in  a  few  hours  he  became 
thirsty,  and  drank  a  large  quantity  of  buttermilk ;  in  the  course  of  the 
evening  he  fell  into  a  state  of  insensibility,  during  which  he  was  con- 
vulsed ;  a  physician  of  great  experience  and  judgment  from  Kilkenny 
was  called  in,  who  opened  the  temporal  artery  immediately  on  seeing  the 
patient,  and  employed  the  usual  means  resorted  to  on  such  occasions ; 
notwithstanding  this,  the  insensibility  continued,  and  in  about  seven 
hours  it  was  observed  that  a  hard  tumour  could  be  felt  distinctly  in  the 
epigastric  region.  This  induced  the  suspicion  of  the  presence  of  some 
undigested  substance,  and  a  strong  purgative  enema  was  therefore  ad- 
ministered ;  its  effect  was  most  satisfactory,  for  after  the  discharge  of 
some  copious  stools  the  tumour  subsided  and  the  boy  recovered  his 
senses.  The  injury  inflicted  on  the  cerebral  system  by  this  violent 
shock  manifested  itself  soon  after  in  the  recurrence  of  the  fit,  and  from 
that  time  forth  he  was  subject  to  epileptic  attacks.  They  annually 
became  more  frequent  and  more  severe,  but  the  vigour  of  his  intellect 
was  not  impaired  until  after  the  disease  had  continued  six  years,  when 
his  mental  faculties  displayed  a  manifest  dulness,  and  in  the  course  of 
a  few  years  more  he  gradually  lapsed  into  idiotcy,  with  however 
occasional  gleams  of  reason,  particularly  on  subjects  connected  with 
religion. 

He  now  remained  entirely  in  the  house,  and  for  many  years  had 
several  epileptic  fits  daily ;  the  convulsive  stage  did  not  usually  last 
more  than  three  or  four  minutes,  but  the  coma  often  continued  nearly 
an  hour.  The  disorder  generally  exhibited  a  manifestly  increased  severity 
twice  a  year,  when  the  fits  would  return  about  ten  times  daily,  and  with 
more  than  ordinary  violence ;  after  such  a  paroxysm  had  lasted  about  a 
week  it  invariably  terminated  in  outrageous  madness,  the  appearance  of 
which  was  a  sure  sign  that  the  paroxysm,  so  far  as  regarded  the  fits,  was 
over ;  this  madness  was  of  the  most  violent  and  noisy  description,  and 
required  restraint ;  when  it  had  subsided,  as  it  usually  did  in  about 
tliree  days,  he  relapsed  into  his  ordinary  state  with  a  few  and  compara- 
tively slight  fits  daily. 

Such  was  the  course  of  the  disease  for  sixteen  years,  during  which 
he  was  most  tenderly  and  assiduously  nursed.  I  ought  to  have  mentioned 
that  a  sudden  and  copious  bleeding  from  the  nose  often  took  place  when 
a  fit  came  on;  the  breathing  was  invariably  violent,  irregular,  and 
heaving,  for  eight  or  ten  minutes  after  the  convulsions  had  ceased,  but 
then  gradually  became  tranquil,  and  so  continued  for  the  remainder  of 
the  comatose  stage.     During  the  last  five  years  of  this  gentleman^s  life 


52G  CLINICAL    MEDICINE. 

the  fits  became  gradually  less  violent,  but  never  ceased ;  for  several 
years  before  his  death  he  remained  free  from  the  attacks  of  madness. 

In  1833,  he  became  subject  to  diarrhoea,  which  recurred  frequently, 
was  difficult  to  stop,  and  seemed  to  have  induced  a  most  depraved  appe- 
tite ;  in  fact  at  certain  times  he  would  swallow  every  thing  he  could  lay 
hold  of,  paper,  coals,  cork,  lead,  glass  (after  due  mastication,)  boxes  of 
family  pills,  straw,  bits  of  books,  &c.  &c.,  from  none  of  which  did  he 
seem  to  sustain  any  permanent  injury.  These  fits  of  depraved  appetite 
used  to  come  on  at  irregular  intervals;  about  1833,  he  began  to  fall 
away  in  flesh,  and  for  the  last  few  years  was  pale,  haggard,  and 
emaciated.  His  sleep  was,  however,  sound,  and  his  appetite  usually 
normal.  About  two  months  before  his  death  the  bowel  complaint  returned 
with  more  than  its  usual  violence,  and  soon  weakened  him  so  much,  that  for 
the  first  time  from  the  commencement  of  his  illness,  he  was  confined  to 
bed,  and  every  thing  failed  to  check  the  diarrhoea,  which  finally  proved 
fatal,  exhibiting  during  its  progress  the  usual  symptoms  of  clironic  in- 
flammation succeeded  by  ulceration  of  the  mucous  membrane  of  the 
intestines. 

While  the  diarrhoea  was  on  him,  and  indeed  all  through  his  illness, 
(except  perhaps  during  the  convulsions,)  his  pulse  was  perfectly  natural, 
slow,  and  soft,  and  so  continued  to  within  two  days  of  his  decease.  The 
respiration  (with  the  exception  formerly  noted)  was  always  perfectly 
natural ;  never  in  the  least  short  or  hurried,  and  he  never  had  a  cough 
until  two  nights  before  he  died,  when  he  had  a  violent  fit  of  coughing 
which  lasted  a  quarter  of  an  hour,  and  was  apparently  stopped  by  a  dose 
of  hartshorn  in  water ;  the  same  happened  on  the  following  night.  He 
was  never  observed  on  any  occasion  to  expectorate,  and  never  had  a  ves- 
tige of  wheezing  in  his  chest,  in  fact  he  was  to  all  appearance  so  free 
from  the  least  suspicion  of  pectoral  complaint,  that  neither  I  nor  any  one 
else  had  examined  his  chest  for  many  years.  It  is  true  that  ever  since 
the  first  epileptic  seizure  he  frequently  complained  of  what  he  termed 
pain  in  his  heart,  and  nineteen  years  ago  he  was  blistered  for  it  by  Dr. 
Ryan,  of  Kilkenny.  This  pain,  referred  invariably  to  the  left  side,  used 
often  to  go  away  for  considerable  intervals,  and  was  consequently  believed 
to  arise  from  a  straining  produced  by  the  violence  of  the  convulsions ; 
during  the  last  year  of  his  life  this  pain  was  very  constantly  complained 
of.  About  three  years  ago  I  saw  him  for  jaundice,  which  lasted  about 
three  weeks,  and  disappeared  without  medicine ;  I  could  not,  at  the 
time,  make  out  the  cause  of  the  jaundice;  he  had  no  pain,  no  fever,  no 
hepatitis. 

The  preceding  history  of  my  patient's  case  is  imperfect,  but  as  far  as 
it  goes,  its  accuracy  may  be  relied  on.     I  am  particularly  anxious  to 


EPILEPSY   WITHOUT    ORGANIC    DISEASE    OF   THE    BRAIN.  5£7 

impress  this  on  your  minds,  before  I  relate  the  result  of  the  post  mortem 
examination,  which  was  conducted  under  the  most  favourable  circum- 
stances, and  at  the  express  wish  of  the  family  of  the  deceased,  by  Dr. 
Lees,  and  Mr.  Quinan,  in  the  presence  of  myself  and  Mr.  Smyly; 
we  had  the  advantage  of  a  well-aired  and  admirably  hghted  room, 
and  during  the  dissection  the  morning  sun  shone  brightly  on  each 
organ  in  succession  as  we  examined  it ;  I  mention  these  facts,  lest  any 
one  should  hereafter  attempt  to  explain  away  the  extraordinary  discre- 
pancy which  this  case  exhibited  between  the  symptoms  observed  during 
life,  and  the  morbid  appearances  discovered  after  death  ;  the  dissection 
was  slowly  and  carefully  conducted,  and  occupied  five  hours. 

The  following  account  will  prove,  that  except  ulceration  of  the  bowels, 
we  found  nothing  we  expected,  and  many  things  totally  unexpected. 

Vast  mortem  Examination  of  Mr.  A.  B.  twenty-four  hours  after 
Death. — Body  emaciated  to  an  extreme  degree  :  the  scalp,  cranium,  dura- 
mater,  arachnoid,  pia  mater,  together  with  the  cortical  and  medullary 
substance  of  both  cerebrum  and  cerebellum,  all  perfectly  healthy ;  a  very 
small  quantity  of  transparent  serum  was  found  in  the  ventricles ;  there 
was  no  notable  sub-arachnoid  effusion.  The  spinal  marrow  and  its  in- 
vestments were  quite  normal. 

The  pleura  pidmonalis  of  the  right  side  was  every  where  intimately 
adherent  to  the  ribs ;  the  right  lung  itself  was  rendered  quite  solid  hy 
tubercles,  which  occupied  its  whole  structure,  and  presented  themselves 
in  every  stage  of  development,  but  no  tubercular  cavities  could  be  de- 
tected; many  crude  tubercles  were  scattered  through  the  otherwise 
healthy  tissue  of  the  lung. 

The  mucous  membrane  of  the  lower  third  of  the  ileum,  of  the  csecum, 
and  colon  was  thickened,  highly  vascular,  and  extensively  ulcerated. 
The  liver  healthy,  gall  bladder  thickened,  not  larger  than  a  wahiut, 
and  entirely  filled  with  a  gall  stone. 

Tliis  case,  to  which  I  shall  again  refer  in  my  lectures  on  phthisis,  as 
an  example  of  the  latent  form  that  disease  sometimes  assumes,  is  in 
many  respects  worthy  of  notice;  in  the  first  place  we  have  here  an 
example  of  a  very  violent  form  of  epilepsy  lasting  for  twenty-one  years, 
giving  rise  to  fatuity,  and  yet  the  most  minute  examination  failed  to 
detect  the  least  trace  of  organic  lesion  in  the  cerebro-spinal  system. 
That  so  formidable  an  affection  of  the  brain  could  continue  for  so  many 
years,  producing  a  daily  recurrence  of  convulsions,  a  frequent  return  of 
violent  mania,  and  a  thorough  dilapidation  of  the  intellect, — that  such 
an  affection  could  continue,  without  the  occurrence  of  any  observable 
changes  of  structure,  is  truly  surprising,  and  militates  strongly  against 
the  doctrine,  on  which  I  have  already  commented,  of  many  modern 


528 


CLINICAL   MEDICINE. 


pathologists^  who  seek  to  explain  every  derangement  of  cerebral  func- 
tion by  the  lesion  found  on  dissection.  I  fully  agree  in  opinion  with 
those  who  maintain  that  epilepsy,  mania,  insanity,  and  fatuity,  rmy 
arise  without  being  caused  by  appreciable  changes  of  structure  in  the 
brain  or  elsewhere. 

In  fine,  without  detracting  from  the  true  value  of  morbid  anatomy, 
these  facts — with  many  others  already  published  by  various  authors — 
prove  that  the  attempt  to  connect  symptoms  with  diseased  alterations  of 
structure  is  attended  with  many  difficulties,  and  is  often  impracticable. 


529 


LECTURE  XXXV. 


DELIRIUM   TREMENS — CHOREA — EPILEPSY. 

Let  me  first,  gentleinen,  direct  your  attention  to  the  case  of  a  man 
above  stairs,  who  had  such  a  comphcation  of  affections  that  it  is  quite 
impossible  to  give  his  disease  a  name.  He  is,  in  fact,  a  kind  of  synopsis 
of  the  phlegmasise.  You  have  seen  him  in  one  of  the  upper  wards,  a 
careless,  idle,  drunken  vagabond,  but  possessed  of  a  constitution  natu- 
rally good.  He  had,  witliin  the  last  few  days,  delirium  tremens,  he 
had  herpetic  eruption  on  the  face,  he  had  violent  bronchitis,  severe 
pneumonia,  inflammation  of  the  mucous  membrane  of  the  stomach  and 
bowels,  inflammation  and  enlargement  of  the  liver.  Here  was  a  com- 
plication of  diseases  extremely  hard  to  treat.  Such  a  complication  ex- 
emphfies  the  advantage  to  be  derived  from  general  treatment.  Erom 
an  attentive  consideration  of  the  manner  in  which  they  arose,  we  were 
enabled  to  treat  in  a  proper  manner  and  overcome  these  diseases. 

In  the  first  place,  this  man  was  a  person  of  intemperate  habits ;  he 
had  walked  about  the  city  for  two  days  and  two  nights  in  a  state  of 
drunkenness,  exposed  to  rain  and  cold.  The  inflammations  by  which 
he  was  attacked  set  in  simultaneously,  or,  at  least,  we  cannot  ascertain 
their  date.  In  the  mean  time,  in  consequence  of  the  feverish  state  of 
the  system,  he  naturally  got  deHrium  tremens.  Now,  I  need  scarcely 
remind  you  that  if  a  man  of  intemperate  habits  gets  any  shock  of  the 
nervous  system,  he  is  likely  to  get  delirium  tremens.  Here  was  a  case 
to  require  accurate  powers  of  diagnosis ;  it  might  have  been  the  deli- 
rium of  fever,  or  of  gastritis,  or  of  bronchitis,  or  of  drinking.  You 
are  aware  that  gastritis,  and  fever,  and  bronchitis,  will  give  rise  to  de- 
lirium, and  that  it  may  attend  typhus  without  inflammation  of  the 
brain  or  engorgement  of  the  vascular  system ;  but  in  this  man's  case, 
when  we  connected  the  disease  with  his  habits  of  intemperance,  and 
looked  to  the  history  of  the  case,  and  observed  that  there  was  nothing 
about  the  head  to  account  for  his  symptoms,  and  from  his  answering 
VOL.  I.  34 


580  CLINICAL   MEDICINE. 

rationally  when  asked  a  question,  we  were  convinced  that  it  was  delirium 
tremens. 

You  know  that  there  are  instances  of  delirium  from  bronchitis,  and 
it  is  an  old  opinion  that  this  arises  from  the  blood  passing  to  the  brain 
in  a  state  not  sufficiently  aerated,  and  the  same  thing  is  adduced  as  the 
cause  of  pain  in  the  head.  But  you  know  that  in  cholera,  where  the 
blood  is  scarcely  aerated  at  all,  there  is  very  httle  pain  in  the  head,  and 
the  intellect  remains  unaffected.  Some  late  experiments,  as  those  of 
Edwards,  Dr.  Marshall  Hall,  and  those  which  have  been  made  in  Edin- 
burgh by  Dr.  Knox,  seem  to  oppose  this  theory  of  the  noxious  influ- 
ence of  blood  not  properly  aerated.  I  think  that  it  arises  rather  from 
engorgement,  as  in  such  cases  the  face  is  generally  congested,  and  the 
lips  purple,  and  that  this  affection  originates  rather  in  congestion 
than  in  a  venous  state  of  the  blood  sent  to  the  brain.  The  reason 
which  induces  me  to  speak  of  this  influence  of  venous  blood,  is  because 
there  are  certain  cases  of  paralysis  from  the  action  of  cold  on  the  lower 
extremities,  which  may  produce  a  permanent  asphyxia  of  the  parts 
affected.  I  knew  a  man,  whose  fingers  remained  of  a  blue  colour  for 
five  months,  except  when  he  put  them  into  warm  water. 

To  return  to  the  case  of  William  Eox.  With  respect  to  the  herpetic 
eruption,  it  is  not  necessary  that  I  should  say  much,  except  that  you 
will  most  commonly  find  it  combined  with  a  feverish  state  of  the  sys- 
tem, which  is  said  to  be  produced  by  cold.  I  shall  also  pass  over  his 
other  diseases,  and  proceed  to  a  more  important  point — the  mode  of 
treatment  to  be  pursued.  Here  we  had  a  number  of  co-existing  dis- 
eases, varying  in  their  seat  and  character,  presenting  a  complexity  of 
indications,  and  requiring  a  nice  adaptation  of  remedial  means.  Eor- 
tunately,  everything  but  the  delirium  tremens  depended  on  inflamma- 
tion :  they  were  all  inflammatory  diseases.  Tliis  gave  us  an  opportunity 
of  employing  the  antiphlogistic  plan  of  treatment,  and  we  adopted  it. 
Tartar  emetic  could  not  be  given  in  consequence  of  the  state  of  his 
stomach  and  bowels ;  and  its  utility,  so  far  as  hepatitis  was  concerned, 
was  extremely  doubtful.  It  might  have  been  prescribed  for  the  delirium 
tremens  with  some  prospect  of  advantage,  for  the  delirium  tremens  here 
was  accompanied  by  a  degree  of  vascular  excitement,  for  which  bleeding 
cannot  be  safely  employed  without  depressing  the  system ;  and  opium 
is  contra-indicated  from  its  tendency  to  increase  congestion :  and,  there- 
fore, as  the  safest  means  of  combating  the  disease,  you  have  recourse 
to  tartar  emetic. 

You  begin  with  the  tartar  emetic ;  you  then  add  a  Httle  opium,  and 
thus  go  on  gradually  increasing  the  latter  until  you  cease  to  give  the 
former,  and  use  opium  alone.     Opium,  if  given  in  the  beginning,  will 


DELIRIUM  TEEMENS.  531 

increase  tlie  congestion  and  bring  on  subarachnoid  effusion.  I  treated 
a  case  of  delirium  tremens  in  this  way  too  boldly,  and  the  man  died 
with  subarachnoid  effusion ;  it  was  a  lesson  to  me,  and  I  would  advise 
you  to  profit  %  my  experience.  Where  you  have  congestion  with  this 
delirium,  bleed  or  leech ;  and  if  you  are  doubtful  of  the  issue  of  blood- 
letting, or  convinced  that  it  is  dangerous,  give  tartar  emetic  with  or 
without  opium,  according  to  circumstances.  In  the  present  instance, 
there  were  other  affections,  namely,  the  pneumonia  and  bronchitis,  which 
called  for  the  use  of  the  lancet.  We  bled  this  man,  therefore,  as  far 
as  his  strength  would  allow,  and  applied  leeches  to  the  epigastrium. 
He  then  got  calomel  in  large  doses,  without  opium,  in  such  a  manner' 
as  to  bring  him  rapidly  under  its  influence.  The  manner  in  which  I 
prescribed  it  is  that  which  is  practised  by  most  physicians  and  surgeons 
in  the  East  Indies.  I  put  about  a  scruple  of  calomel  on  the  tongue, 
and  let  the  patient  swallow  it  without  any  liquid,  or  wash  it  down  with 
a  little  cold  water. 

The  next  case  I  shall  call  your  attention  to  is  that  of  the  man  named 
Eeddy,  aged  27  ;  he  was  a  workman  in  the  porter  brewery  of  the 
Messrs.  Guinness,  and  was  in  the  habit  of  consuming  daily  large  quan- 
tities of  their  famous  XX  porter,  besides  whiskey.  Three  weeks  before 
admission  he  was  attacked  with  rheumatism  in  all  the  large  joints, 
which,  when  we  saw  him,  were  swollen,  red,  and  painful ;  the  fingers 
of  both  hands  were  semiflexed,  and  he  could  not  bear  them  to  be 
touched ;  his  countenance  was  dejected,  and  expressive  of  intense  suf- 
fering; pulse  72,  weak  but  regular;  heart's  action  normal;  profuse 
sweating;  inability  to  move  in  bed;  insomnia;  loss  of  appetite  and 
thirst.  He  was  bled  and  put  on  the  use  of  calomel  and  opium ;  the 
quantity  of  opium  taken  daily  w2isfour  grains. 

The  next  day,  21st,  pericarditis  was  detected.  There  was  nothing 
remarkable  in  the  signs;  the  mercury  and  opium  were  continued;  cup- 
ping over  the  heart  followed  by  blisters  directed,  and  on  the  twenty- 
fifth  salivation  set  in ;  the  cardiac  symptoms  subsided,  and  the  inflam- 
mation of  the  joints  greatly  disappeared.  The  quantity  of  calomel  was 
diminished  from  twelve  grains  daily,  combined  with  four  grains  of  opium, 
to  three  of  the  former  with  one-fourth  of  the  latter  every  second  day. 
On  the  26th  the  rheumatism  appeared  much  relieved,  and  the  pulse  was 
88,  soft  and  regular,  yet  there  was  something  unusual  about  his  ap- 
pearance ;  his  countenance  w^as  excited  and  his  eyes  bright,  and  on 
inquiry  we  ascertained  that  he  had  slept  none  during  the  night,  and 
that  he  had  raved  the  whole  time,  occasionally  shouting  and  singing. 
On  the  27th  he  was  much  worse,  he  lay  quite  prostrated  on  the  bed, 
the  upper  part  of  his  body  was  covered  with  a  profuse  perspiration,  he 


532  CLINICAL  MEDICINE. 

had  twitching  of  all  the  muscles  of  the  face,  subsultus,  and  tremor  of 
lower  limbs ;  he  slept  none,  but  raved  aU  night,  and  about  three  o'clock, 
A.M.,  got  out  of  bed,  and  endeavoured  to  break  through  a  door  into  the 
adjoining  ward.  His  tongue  was  dry  and  unsteady  whftn  protruded ; 
he  answered  questions,  however,  rationally,  and  said  he  had  no  head- 
ache;  pulse  116,  very  weak. 

He  was  now  ordered  one  grain  of  opium,  in  the  form  of  piU,  every 
fourth  hour,  and  four  ounces  of  wine  in  the  day. 

On  the  28th  the  report  states  that  he  fell  asleep  after  the  third  pill, 
(about  eleven  o'clock),  and  did  not  waken  for  six  or  seven  hours,  when 
he  again  commenced  shouting  and  singing,  but  soon  became  quiet,  and 
at  eight  o'clock  the  following  day  the  tremors  had  greatly  diminished ; 
his  countenance  was  vastly  improved,  skin  cool,  tongue  steady  when 
protruded,  but  dry  and  furred,  and  his  intellect  restored.  It  was  found 
necessary  to  increase  the  wine  from  four  to  sixteen  ounces  since  the  27th. 

On  the  28th  all  the  symptoms  of  delirium  tremens  had  vanished;  he 
was  free  from  headache,  his  skin  cool,  tongue  moist,  and  no  thirst,  and 
the  pains  in  the  joints  nearly  gone. 

The  wine  and  opium  wTre  now  diminished  gradually,  and  in  ten  days 
after,  he  was  discharged  perfectly  cured. 

The  complication  of  delirium  tremens  with  acute  rheumatism,  is  not 
by  any  means  common ;  and  it  is  remarkable,  that  in  this  case  the  first 
symptoms  of  the  affection  manifested  themselves  the  day  after  the  quan- 
tity of  opium  was  diminished.  Can  we  explain  this  by  supposing  that 
the  opium  acted  as  a  stimulant,  and  that  being  stopped  suddenly,  it 
produced  the  same  train  of  symptoms  that  usually  foUow  the  leaving  off 
of  any  strong  stimulant  that  had  previously  been  largely  indulged  in  ? 

This  explanation  may  seem  at  first  plausible,  but  we  know  from  ex- 
perience, that  when  opium  acts  heneficially ^  as  a  remedial  agent,  it  sel- 
dom produces  any  of  the  bad  consequences  that  follow  its  exhibition  in 
a  healthy  state  of  the  body,  an  illustration  of  which  this  case  affords  : 
for  we  find  that  it  neither  occasioned  headache,  heat  of  skin,  furred 
tongue,  thirst,  contracted  pupil,  nor  acceleration  of  the  pulse.  We 
must,  therefore,  look  upon  the  circumstance  as  a  mere  coincidence,  and 
we  can  easily  comprehend  how  delirium  tremens  might  occur  in  a 
patient  of  intemperate  habits  during  the  course  of  a  painful  illness,  by 
which  he  was  much  reduced  and  worn  down. 

Let  me  next  call  your  attention  to  some  points  connected  with  the 
treatment  of  chorea.  In  general  chorea  is  a  disease  yielding  to  treat- 
ment with  sufficient  ease,  but  examples  occur  now  and  then  requiring 
great  assiduity  and  patience,  and  some  which  even  baffle  all  attempts  at 


CHOREA.  533 

cure.     The  best  treatise  I  know  on  this  subject  is  contained  in  the 
article  Chorea,  in  Copland's  Dictionary  of  Practical  Medicine. 

The  following  case  was  seen  by  Mr.  Mulock,  Sir  Philip  Crampton, 
Sir  Henry  Marsh,  and  myself,  and  exhibits  in  a  striking  point  of  view 
the  difficulties  the  physician  has  to  contend  with  in  the  treatment  of 
the  aggravated  form  of  chorea,  as  well  as  the  inefficiency  of  some  of  the 
best  reputed  medicines  and  the  striking  utility  of  others.  The  young 
lady  was  attacked  on  the  17th  of  April  with  the  first  symptoms  of  cho- 
rea, affecting  one  side  of  the  body  only.  In  the  course  of  twenty-four 
hours,  the  peculiar  motions  of  chorea  had  extended  to  all  her  limbs,  and 
became  hourly  worse.  For  the  first  few  days  of  her  illness  she  could 
walk  although  unsteadily,  but  she  soon  lost  this  power  altogether,  so 
strong  and  uncontrollable  did  the  involuntary  motions  of  her  legs  be- 
come. At  the  same  time  she  became  incapable  of  raising  her  arms  and 
hands,  as  they  were  perpetually  jerking  about  in  every  direction.  In- 
deed the  rapidity  with  which  the  disease  progressed  was  remarkable,  for 
in  the  course  of  a  week  from  its  first  beginning  it  had  assumed  a  degree 
of  intensity  and  violence  which  had  no  parallel  in  the  experience  either 
of  Sir  Philip  Crampton,  Mr.  CoUes,  or  Sir  Henry  Marsh. 

When  at  its  height  the  disease  presented  a  truly  appalling  spectacle ; 
every  part  of  the  system  of  voluntary  muscles  seemed  to  be  aff'ected ;  aU 
the  directing  influence  of  volition  had  ceased,  and  the  muscles  every 
where  were  agitated  by  sudden,  violent,  and  jerking  motions,  which  con- 
stantly and  forcibly  changed  the  position  of  her  limbs,  throwing  her 
into  attitudes  the  most  varied,  and  succeeding  each  other  with  extra- 
ordinary rapidity.  Her  arms  were  indeed  thrown  about  with  such  force 
that  it  became  necessary  to  cover  with  blankets  and  soft  padding  the 
sides  of  the  sofa  on  which  she  lay,  and  in  spite  of  this  and  other  pre- 
cautions her  limbs  were  soon  covered  with  bruises.  Her  state  was 
truly  pitiable ;  one  or  two  persons  were  constantly  engaged  in  prevent- 
ing her  from  rolling  off  the  couch ;  now  and  then  she  sat  up  suddenly, 
made  an  involuntary  effort  to  assume  the  erect  position,  and  as  suddenly 
flung  herself  down ;  meanwhile  her  limbs  were  flexed,  extended,  tlu"0wn 
backwards  and  forwards  with  unceasing  rapidity.  At  one  moment  her 
hand  would  be  struck  against  her  head,  and  at  the  next  be  passed  be- 
hind the  back.  It  was  almost  impossible  to  keep  her  covered  with 
clothes,  for  the  constant  motion  of  the  limbs  often  tossed  the  sheets, 
blankets,  and  quilts  oft'  together,  and  not  unfrequently  even  stripped 
her  of  her  stockings. 

At  the  height  of  her  illness  the  motions  of  her  limbs  and  body  were 
quite  extraordinary,  and  appeared  to  be  such  as  could  be  only  performed 
by  a  person  whose  very  bones  were  pliant  and  flexible.     She  soon  lost 


534)  CLINICAL   MEDICINE. 

all  power  of  articulation,  and  during  a  period  of  three  weeks  she  was 
not  able  to  put  out  her  tongue,  or  speak  a  single  word.  The  muscles  of 
deglutition  became  engaged  in  the  disease,  but  the  muscular  system  of 
respiration,  circulation,  and  digestion,  was  unaffected  throughout  the 
disease ;  hence  her  breatliing  and  pulse  were  natural,  and  her  digestion 
and  alvine  evacuations  regular.  A  continuance  of  muscular  exertion,  so 
violent  although  involuntary,  could  not  fail  rapidly  to  exhaust  the  sys- 
tem, and  accordingly  she  lost  her  flesh  daily,  and  before  the  middle  of 
May,  that  is  in  four  weeks,  her  emaciation  had  become  extreme.  Her 
countenance  was  sunk,  her  pulse  weak,  the  whole  surface  of  the  body 
was  excoriated  from  the  friction  unavoidably  produced  by  the  constant 
movement  of  both  trunk  and  extremities. 

This  rendered  all  attempts  to  act  on  the  disease  through  the  medium 
of  the  skin  quite  hopeless.  Leeches,  plasters,  blisters,  liniments,  could 
not  be  applied  ;  it  was  even  impossible  to  administer  a  lavement. 
During  sleep,  and  during  sleep  only,  had  she  respite  from  the  muscular 
labours ;  then  she  lay  quiet.  The  liquor  of  the  muriate  of  morphia 
proved  very  serviceable  indeed  in  procuring  sleep,  and  did  not  appear 
to  produce  headache,  constipation,  or  any  other  inconvenience.  I 
should,  however,  remark,  that  her  intellect  was  unafi'ected,  and  her 
head  quite  free  from  pain  except  for  a  few  days  previously  to  the  occur- 
rence of  epistaxis  in  the  beginning  of  the  attack.  Her  appetite  conti- 
nued good  throughout.  The  following  brief  sketch  of  this  case  has 
been  given  me  by  Mr.  Mulock  of  Charlemont-street : — 

S.  W.,  aged  15,  was  affected  with  influenza  in  the  beginning  of  April, 
and  relieved  in  a  few  days ;  she  continued  well  until  the  seventeenth, 
when  she  had  a  shght  hysteric  illness,  with  tossing  of  the  left  hand  and 
arm  :  Dr.  Graves  saw  her  on  the  morning  of  the  eighteenth ;  the  dis- 
ease was  then  manifestly  an  attack  of  chorea ;  the  menses  had  appeared 
about  two  months  previously,  but  not  afterwards :  Dr.  Graves  ordered 
aloetic  pills  combined  with  calomel,  at  night,  and  a  brisk  saline  aperient 
in  the  morning.  She  appeared  to  amend  for  a  few  days  in  her  general 
health,  but  the  tossing  of  the  limbs,  &c.,  increased ;  he  then  directed 
aloetic  mixture  with  iron ;  I  should  mention  that  the  pulse  was  natural, 
and  tongue  not  loaded.  After  taking  these  draughts  for  two  days  the 
countenance  flushed,  and  she  had  a  slight  hemorrhage  from  the  nose ; 
Dr.  Graves  left  off  the  draughts,  and  ordered  vegetable  jellies,  without 
either  meat  or  wine. 

Sir  Philip  Crampton  saw  her  at  this  time  in  consultation;  he  said  the 
only  case  he  had  latterly,  was  relieved  by  oil  of  turpentine,  given  in 
decoction  of  aloes ;  she  took  two  of  these  draughts,  but  they  pro- 
duced so  much  excitement,  we  were  obliged  to  give  them  up  ;  the  tongue 


CHOREA.  535 

became  also  swollen,  and  there  was  great  dijSiculty  in  swallowing, 
indeed  a  person  was  obliged  to  eat  before  her  to  enable  her  by  imitation 
to  do  so.  Both  sides  were  now  effected ;  liquids  passed  out  of  the  side 
of  the  mouth ;  it  was  impossible  to  give  medicine  either  by  enema  or  in 
pills.  Dr.  CoUes  was  called  in  consultation  ;  he  ordered  carbonate  of 
iron  and  rhubarb  in  an  electuary  :  it  could  not  be  taken,  though  often 
tried.  Dr.  Graves  then  considered  that  medicine  ordered  in  the  form 
of  a  lozenge  could  be  swallowed ;  he  thought  the  liquor  arsenicalis  in 
that  form  would  be  useful ;  this  was  tried  for  two  days  and  appeared  to 
be  of  service,  with  twenty-five  drops  of  the  solution  of  muriate  of 
morphia,  and  four  drops  of  the  oil  of  peppermint  on  sugar  at  night: 
the  only  time  jactitation  of  the  limbs,  &c.,  stopped,  was  when  sleep  was 
procured. 

The  prescription  for  the  lozenge  w^as  : 

R  Liquoris  Arsenicalis,  gtts.  xviii. 

Pulveris  Gummi  Arabici,  3ss. 

Sacchari  albi,  gr.  xxv. 
Misce  et  fiat  secundum  artem  massa. 
Divide  in  partes  sex  sequales,  sumat  unam  ter  in  die. 

The  disease  now  appeared  to  be  hysteria  combined  with  chorea,  as 
there  were  constant  sobbing,  heaving  of  the  chest,  and  other  hysteric 
symptoms,  along  with  incessant  tossing  of  the  head,  limbs,  &c.,  twisting 
of  the  eyes  and  mouth.  She  continued  the  liquor  arsenicalis  with 
muriate  of  morphia  for  three  days ;  she  had  some  rest,  but  when  not 
under  the  influence  of  the  morphia  the  disease  appeared  unaltered.  Sir 
Henry  Marsh  saw  her  in  consultation  on  the  16th  of  May,  and  ordered 
quina  with  extract  of  stramonium,  and  tepid  salt  water  shower  baths 
three  times  a  day ;  these  were  obliged  to  be  given  while  lying  on  a  hair 
mattress  :  and  to  continue  the  anodyne  at  night.  After  taking  IJ  grains 
of  stramonium,  dilatation  of  the  pupils  took  place,  and  it  was  thought 
prudent  to^  leave  off  the  medicine  for  some  hours ;  the  tossing  of  the 
limbs,  &c.,  and  difficulty  of  swallowing  gradually  abated. 

The  form  for  the  stramonium  lozenges  was  : 

R  Sulphatis  Quinoe,  gr.  viii. 
Extracti  Stramonii,  gr.  1|. 
Pulveris  Glycyrrhizse,  gr,  xv. 
Theriacse  quantum  sufficit. 
Fiat  massa,  et  divide  in  partes  quatuor.     Sumat  unam  quater  in  die. 

The  entire  skin,  previous  to  using  the  baths,  on  the  shoulders,  sides, 
and  cheeks,  &c.,  was  in  such  a  state  of  irritation  from  the  constant  fric- 
tion as  to  require  to  be  constantly  washed  with  Eau  de  Cologne. 

19th.  The  uneasiness  was  much  lessened,  the  bath  was   of  much 


536  CLINICAL   MEDICINE. 

service ;  lier  diet  from  tlie  fourteenth  was  generous,  as  emaciation  was 
extreme  from  the  trifling  sleep  and  constant  motion ;  she  has  now  taken 
the  lozenges  for  eight  days,  and  continues  to  improve ;  she  can  also 
take  the  bath  sitting  in  an  oval  tub,  wliich  has  been  lined  with  wool 
and  covered  over  with  coarse  cloth  to  prevent  her  hurting  herself :  the 
stramonium  after  the  second  day  did  not  appear  to  affect  the  pupils. 

In  this  case  the  failure  of  all  remedies  until  we  tried  the  shower  bath 
and  the  combination  of  sulphate  of  quina  and  extract  of  stramonium, 
recommended  by  Sir  Henry  Marsh,  was  not  more  remarkable  than  the 
rapid  improvement  wliich  took  place  after  the  new  plan  had  been  adopted, 
indeed  at  the  time  I  speak  of,  I  considered  her  case  as  nearly  hopeless, 
and  believed  that  a  few  days  would  close  the  scene  of  her  sufferings. 

The  shower  bath  was  used  at  first  warm,  and  then  tepid.  Its  appli- 
cation was  very  difficult ;  the  plan  pursued  was  to  place  the  patient  on  a 
large  mattress  covered  with  a  blanket,  where  she  was  held  by  an  assis- 
tant destined  unavoidably  to  enjoy  the  bath  along  with  her :  other  ser- 
vants, mounted  on  chairs,  then  poured  the  water  from  several  large 
watering  pots,  held  high,  on  the  patient  beneath;  when  this  was  done 
she  was  taken  into  another  room,  well  dried,  and  then  covered. 

This  operation,  however  troublesome,  was  perseveringly  repeated 
three  times  daily ;  as  she  improved,  the  application  of  the  shower  bath 
was  attended  with  less  flooding  of  the  apartment,  as  she  could  then  be 
placed  in  a  large  stuffed  tub  to  receive  the  affusion.  From  a  careful 
observation  of  the  effect  of  the  remedies,  I  am  inclined  to  attribute  the 
improvement  more  to  the  shower  bath  than  to  the  sulphate  of  quina  or 
stramonium,  although  the  effects  of  the  latter  on  the  system  must  have 
been  powerful,  for  in  a  few  hours  after  commencing  its  use,  her  pupils 
were  dilated  to  a  maximum.  Be  this  as  it  may,  this  combination  of 
remedies  produced  a  change  the  most  astonisliing,  and  she  regained 
flesh,  colour,  strength,  and  command  of  her  muscles,  so  rapidly,  that 
now  but  a  slight  vestige  of  the  complaint  remains. 

The  powerful  efi'ects  of  water  whether  hot,  tepid,  or  cold,  poured  on 
the  naked  skin,  may  be  illustrated  by  many  facts,  but  it  is  not  easy  to 
determine  whether  those  effects  are  owing  to  the  impression  made  on 
the  sensation  of  the  cutaneous  nerves  by  the  temperature  of  the  fluid, 
or  to  the  force  with  which  it  is  applied  to  the  surface.  Both  probably 
concur  in  making  affusion  of  water  so  effectual  a  remedy :  by  means  of 
cold  affusion,  hysterical  fits  and  convulsive  disease  are  frequently 
checked,  and  persons  narcotized  by  opium  or  prussic  acid  are  most 
speedily  awakened.  Water  appHed  to  the  surface,  whether  in  a  con- 
tinued and  forcible  stream,  as  a  douche,  or  in  the  usual  manner  by 
means  of  the  shower  bath,  frequently  produces  much  benefit  in  diseases. 


CHOHEA.  537 

general  and  local,  acute  and  chronic.  The  case  I  have  just  related 
affords  an  additional  example  of  the  beneficial  employment  of  this  remedy. 

Since  this  case  occurred,  I  was  induced  by  the  reported  beneficial 
effects  of  sulphate  of  zinc  in  certain  spasmodic  diseases,  whether  of  an 
hysterical  or  of  a  truly  epileptic  nature,  to  try  its  efficacy  in  chorea,  and 
I  can  assert  with  confidence  that  no  other  single  remedy  is  so  generally 
useful.  In  several  severe  cases  it  has,  without  the  aid  of  any  other 
medicine,  cured  the  patient  speedily  and  perfectly.  In  one  case,  which 
I  saw  with  Mr.  Barker,  it  failed  altogether,  and  so  did  everything  we 
tried,  except  opium ;  which,  however,  was  only  useful  in  so  far  that  it 
procured  sleep  at  night,  without  which  the  patient,  a  boy  of  thirteen, 
must  have  been  speedily  worn  out,  so  violent  and  continued  were  the 
spasmodic  motions  of  the  affected  limbs.  In  the  case  referred  to,  time 
gradually  brought  about  recovery.  The  sulphate  of  zinc  may  be  given 
simply  dissolved  in  rose-water,  in  half-grain  doses,  repeated  often  in  the 
day.  When  tolerance  of  the  salt  on  the  part  of  the  stomach  is  obtained, 
it  will  be  often  bonie  to  the  amount  of  ten  or  fifteen  grains  in  the  day ; 
but  we  must  always  study  its  effects,  and  use  the  smallest  quantity  that 
will  ensure  a  cure. 

Authors  who  have  written  on  the  subject  of  chorea  agree  in  stating 
that  it  very  seldom  persists  after  puberty.  "  We  see  little  of  it,"  says 
Dr.  Blackmore,  "  in  adults,  yet  it  will  sometimes  continue  for  the  whole 
life.''  It  appears  plain,  from  this  observation,  that  Dr.  Blackmore  had 
never  witnessed  the  first  access  of  chorea  at  an  advanced  age,  and  con- 
sequently I  think  it  right  to  mention  that  Dr.  Ireland  consulted  me 
formerly  respecting  the  late  Mr.  Dyas,  a  respectable  apothecary  residing 
in  Castle- street,  who,  when  seventy  years  old,  was  attacked  by  chorea 
in  as  uncomplicated  a  form  as  I  ever  saw.  The  disease  was  very  severe, 
and  lasted  many  months.  Thus  do  diseases  of  the  nervous  system, 
like  the  waning  intellect,  affect  a  second  childhood  ! 

The  following,  another  instance  of  chorea  occurring  for  the  first  time 
in  advanced  life,  was  communicated  to  me  by  Dr.Patton  of  Tanderagee: — 

"The  patient  is  a  woman  aged  50  ;  four  years  since  her  husband  left 
her,  and  two  or  three  of  her  children  removed  from  this  country  to 
Scotland.  She  became  much  depressed  in  spirits  and  fretted  a  good 
deal ;  she  then  had  startings  in  her  sleep  and  annoyance  from  flatu- 
lence, then  the  chorea  came  on  at  the  end  of  a  year,  and  continued,  at 
first  being  severe,  but  with  intermissions,  during  which  she  felt  in 
better  spirits — the  approach  of  the  attack  was  ushered  in  after  each 
intermission,  by  lowness  of  spirits  and  sighing ;  the  motions  during  the 
night  and  startings  in  sleep  were  not  severe,  but  never  left  her  completely. 
The  disease  has  now,   (July,  1847,)  continued  three  years,- the  violent 


538  CLINICAL  MEDICINE. 

attacks  never  occur  at  present,  but  slight  ones  which  are  always  aggra- 
vated when  the  moon  is  changing,  or  when  she  has  suffered  fatigue  or 
anxiety.  She  has  never  been  epileptic  or  had  a  convulsion,  is  active 
for  her  time  of  hfe,  and  has  a  very  healthy  aspect.  The  catamenia 
ceased  ten  years  since."" 

I  have  just  now  mentioned  the  good  effects  of  sulphate  of  zinc  in 
convulsive  diseases,  the  following  case  is  a  good  example  of  the  benefit 
it  sometimes  produces  in  epilepsy  : — T.  A.,  set.  39,  unmarried,  of  full 
habit,  liable  for  years  to  bilious  attacks,  and  suffering  occasionally  from 
hemorrhoids,  which  bleed  at  times — after  labouring  for  several  months 
under  dyspepsia — about  the  end  of  Sept.  1843,  being  more  than 
usually  fatigued  by  continued  mental  and  bodily  exertion,  was  seized 
with  a  fit,  in  whicli  he  fell  from  his  chair  insensible,  but  was  after  a  little 
able  to  get  up  and  go  to  his  bed  unassisted.  He  was  again  seized  about 
the  end  of  November  in  the  morning  whilst  dressing,  the  fit  continuing 
from  about  five  to  eight  minutes,  not  preceded  by  any  unpleasant  feel- 
ings, nor  followed  by  any  bad  consequences.  About  the  middle  of 
December,  same  year,  he  was  seized  with  another  fit  of  the  same  kind, 
but  of  longer  duration  and  severer  character,  in  which  the  tongue  was 
injured  by  the  teeth ;  this  fit  was  followed  by  great  muscular  soreness 
and  lassitude,  much  depression  of  spirits,  nervous  anxiety,  irritabihty  of 
temper,  and  disinclination  to  pursue  usual  avocations,  from  the  mind 
becoming  easily  fatigued  and  confused.  In  tliis  paroxysm,  as  in  two  or 
three  succeeding,  there  was  frothing  from  the  mouth,  stertorous  breath- 
ing, with  rigidity  of  muscular  system,  followed  towards  the  termination 
by  occasional  twitchings  of  right  hand  and  arm.  In  none  was  there 
from  the  first  to  the  present  any  inchnation  to  sleep  towards  the  termi- 
nation of  the  fit  or  afterwards,  and  in  some  time  on  taxing  the  memory, 
every  occurrence  up  to  the  moment  of  seizure  and  from  its  termination, 
could  be  distinctly  remembered.  In  general,  the  fits  are  immediately 
preceded  by  foolish  unconnected  ideas,  some  muttering,  a  sense  of  suf- 
focation, and  sometimes  a  scream,  and  in  some,  but  not  all,  there  is 
seminal  emission. 

There  was  no  treatment  adopted  till  this  period,  when,  in  the  last 
attack,  from  twelve  to  sixteen  ounces  of  blood  were  taken  from  the  arm. 
On  consulting  a  medical  man  sometime  early  in  February,  ]  844,  he  was 
ordered  gamboge  pill  with  calomel,  occasionally  followed  by  black 
draught,  five  grains  of  assafoetida  twice  daily,  to  use  the  shower-bath, 
and  to  relieve  the  mind  as  much  as  possible  from  business.  After  con- 
tinuing this  plan,  which  had  the  effect  of  regulating  the  bowels  and 
lessening  in  some  degree  nervous  irritability,  without  otherwise  causing 


EPILEPSY.  539 

any  great  change  in  symptoms  until  June  1844^ — the  attacks  becoming 
if  any  thing  more  frequent  but  less  severe,  he  left  home  to  try  what 
change  of  air  and  variety  would  do ;  this  he  found  of  use,  as  the  fits 
became  less  frequent  as  well  as  less  severe. 

At  this  time,  while  in  London,  sometime  in  the  end  of  July,  1844,  he 
was  advised  to  be  cupped  occasionally  from  the  nape  of  the  neck  if  any 
fulness  of  head  was  experienced;  which  was  done  four  times,  to  about  six 
or  eight  ounces  each  operation:  to  take  four  ounces  of  infusion  of  quassia 
twice  daily,  to  act  on  the  bowels  when  necessary  with  the  same  pill  as 
before  used,  to  take  as  much  walking  exercise  as  possible,  to  leave  off 
eating  vegetables,  to  live  on  animal  food  and  bread,  and  not  to  take 
more  than  two  glasses  of  wine,  or  half  a  glass  of  brandy  and  water  at 
and  after  dinner.  He  followed  tliis  plan  till  Sept.  1844;  it  had  the 
effect  of  giving  tone  to  the  stomach  and  bowels ;  the  nervous  system 
gradually  gaining  strength,  with  a  longer  intermission  than  any  before. 

But  he  was  again  seized  with  a  severe  fit  in  September,  1844,  after 
which  he  was  ordered  to  take  sulphate  of  zinc,  made  into  pill,  with 
extract  of  gentian,  and  to  increase  the  quantity  as  much  as  possible ;  to 
continue  the  exercise  so  as  to  reduce  corpulency,  and  after  a  time  to 
alternate  the  zinc  with  the  sulphate  of  quina,  regulating  the  dose  of  it 
as  of  the  former.  He  began  the  zinc  in  Sept.  1844,  in  three  grain 
doses  three  times  a-day,  and  increased  it  to  ten ;  at  the  end  of  twelve 
weeks,  during  which  time  it  was  regularly  taken,  he  left  off  its  use  and 
began  the  quina,  taking  it  in  much  the  same  doses,  and  alternating  them 
occasionally,  but  taking  the  sulphate  of  zinc  as  the  principal  remedy  till 
March,  1845. 

This  treatment  had  the  effect  of  prolonging  the  next  intermission  till 
about  the  middle  of  November,  at  which  time  he  had  a  slight  attack. 
About  that  time  the  spasmodic  action  of  the  hand  and  arm  (before  de- 
scribed as  occuring  in  the  fit)  now  appeared  during  the  intermissions  at 
irregular  times,  often  twice  or  thrice  in  the  day,  at  others,  not  for  days 
together,  and  increased  so  much  that  it  was  not  under  the  control  of 
the  will,  being  often  obliged  to  grasp  anything  within  reach ;  it  also 
affected  the  right  leg,  not  so  powerfully  however,  and  preceded  by  an 
unpleasant  kind  of  shock,  felt  for  the  first  time,  passing  tlirough  the 
whole  system,  and  continuing  severe  till  about  July,  1845,  from  which 
time  it  began  to  lessen  in  severity  and  frequency,  but  recurs  occasionally 
to  the  present.  Trom  about  the  second  or  third  attack  of  the  disease  to 
the  present,  there  is  at  uncertain  periods,  often  twice,  sometimes  thrice 
a-day,  again,  not  perhaps  for  two  or  three  days,  a  kind  of  oblivious 
state  experienced  for  a  minute  or  so,  then  going  off  without  any  particular 
results  :  tliis  continues  up  to  the  present. 


540  CLINICAL  MEDICINE. 

Erom  the  last  attack  wliicli  occurred  in  Nov.  ]  844,  lie  had  a  longer 
interval  than  any  since  the  commencement  of  the  disease,  but  after  using 
zinc  and  quina,  as  I  before  stated,  for  about  six  months,  he  got  tired  of 
them,  and  left  off  their  use.  They  had  the  effect  of  prolonging  the  in- 
tervals, and  in  some  measure  lessening  the  fits.  Tor  some  time  before 
the  zinc  was  left  off,  there  was  felt  a  kind  of  metallic  taste  of  mouth, 
evidently  indicating  that  the  system  was  saturated  with  the  remedy.  The 
paroxysms  have  continued  from  the  date  of  the  last,  reported  in  Nov. 
1844,  to  the  present  (the  last  occurring  27th  Jan.,  1846,)  at  uncertain 
intervals,  ranging  from  three  to  five,  eight,  and  sometimes  twelve  or 
fifteen  weeks,  and  with  varied  degrees  of  severity. 

The  following  are  the  dates  of  the  attacks  in  this  case,  extending  over 
a  period  of  three  years  ;  from  them  you  will  see  the  effects  of  the  sul- 
phate of  zinc  in  prolonging  the  intervals  between  the  fits  : — 1843,  Sept. 
26th,  Nov.  25th,  Dec.  18th;  1844,  Peb.  5th,  until  Sept.  3rd,  when  he 
commenced  to  take  the  zinc,  he  had  five  fits ;  and  from  this  time  until 
Eeb.  1846,  a  period  of  eighteen  months,  he  had  but  nine  fits,  or  one 
every  second  month,  wliile  previously  he  had  one  every  month. 

In  another  case  in  which  I  was  consulted  by  Dr.  Taylor  of  Bailie- 
borough,  I  gave  the  sulphate  of  zinc  in  much  larger  doses,  but  without 
any  evident  advantage.  I  mention  it  to  you  chiefly  as  showing  the 
quantity  of  tliis  medicine  that  may  be  given  without  producing  any  in- 
jurious effects.  According  to  Dr.  Taylor's  report,  I  recommended  him 
on  August  5th,  1845,  to  begin  the  treatment  of  the  case,  that  of  a 
young  lady,  by  administering  "  one  grain  of  the  sulphate  of  zinc  four 
times  a  day  for  three  days,  then  one  grain  to  be  added  to  each  dose 
at  the  end  of  every  three  days,  until  eight  grains  were  taken  at  a 
dose  four  times  a-day.  This  course  having  been  strictly  attended  to 
she  was  able  at  the  end  of  the  month  to  take  eight  grains  four 
times  in  the  day.  During  this  month  she  had  four  fits.  About 
tliis  time  she  complained  of  sickness  of  stomach  immediately  after 
taking  the  medicine,  but  by  omitting  one  dose  daily  for  one  or  two 
days  she  was  able  to  take  the  full  quantity.  From  the  8th  of  Sep- 
tember to  the  22nd  of  October,  she  was  occasionally  able  to  take  40 
grains  a  day,  and  had  11  fits,  the  majority  of  them  of  more  than  ordi- 
nary severity.  Previous  to  this  time  I  wrote  to  Dr.  Graves  on  the  sub- 
ject, and  by  his  advice  continued  the  medicine  at  the  same  rate,  until 
about  the  23rd  of  November,  when  I  received  a  letter  from  him  in 
which  he  stated  that  he  thought  it  would  be  injudicious  to  persevere 
longer  in  the  use  of  the  medicine,  and  that  he  would  advise  the  quantity 
to  be  diminished  two  grains  daily  for  a  fortnight,  when  she  should  be 
put  on  the  use  of  valerian,  camphor,  and  aromatic  spirit  of  ammonia,  in 


EPILEPSY.  541 

doses  sufficient  to  counteract  the  general  marasmus  of  the  system 
which  then  prevailed  to  a  very  considerable  extent/' 

It  is  right  that  I  should  mention  to  you  here  that  the  preparations  of 
zinc  when  their  use  has  been  long  continued  have  been  described  as 
producing  general  marasmus ;  you  should  therefore  be  careful  not  to 
continue  their  administration  too  long ;  it  is  evident  that  in  the  case  I 
have  been  now  speaking  of,  this  effect  was  beginning  to  be  produced, 
I  therefore  stopped  the  use  of  the  sulphate  gradually. 

Before  concluding,  I  wish  to  lay  before  you  the  particulars  of  another 
case  of  epilepsy  derived  from  the  patient's  own  account,  a  gentleman  of 
the  highest  talent  and  most  accurate  observation.  It  is  an  example  of 
epilepsy  depending  on  injury  to  the  bones  of  the  cranium,  but  not  occur- 
ring for  some  years  after  the  accident  by  which  the  injury  was  produced. 
The  following  was  his  statement  on  consulting  me : — "  About  25  years 
since,  driving  out  with  my  servant  in  a  gig,  I  suddenly  lost  my  speech, 
and  was  conscious  of  it  for  a  short  time,  making  signs  to  him  to  drive 
home,  and  then  became  insensible  for  20  minutes  or  half  an  hour  as  I 
was  told.  After  this  I  had  repeated  attacks  of  the  same  kind,  having 
suffered  previously  from  intense  headache  and  intolerance  of  light,  I 
came  to  Dublin  for  advice,  and  consulted  the  most  eminent  physicians 
of  the  day  with  little  advantage  for  a  fortnight  or  three  weeks,  when  on 
going  one  day  to  meet  them,  I  observed  that  a  swelling  and  tenderness 
had  appeared  on  the  top  of  the  head,  this  was  immediately  examined, 
and  I  then  recollected,  and  told  them,  that  three  or  four  years  before,  I 
had  been  riding  rapidly  along  the  road,  and  my  horse  had  suddenly 
fallen,  cutting  its  head  and  not  the  knees,  that  my  hat  was  cut  and 
dinged,  and  on  rising  on  my  feet,  I  felt  dizzy  and  confused,  from  which 
I  soon  recovered.  The  swelling  was  then  opened  with  caustic,  and 
after  some  time  portions  of  diseased  bone  came  away.  Before  I  came 
up  to  Dubhn  a  seton  had  been  tried  in  the  neck,  but  with  little  advan- 
tage— this  seems  to  be  the  commencement  of  my  disease. 

"  It  is  at  varied  intervals  that  loss  of  speech  and  insensibility  have 
since  occurred,  sometimes  after  years,  at  others  three  or  four  months,  but 
only  once  or  twice  so  soon — and  then  only  the  bewildered  feel,  unable  to 
articulate  or  to  write  (which  I  have  attempted),  without  the  insensible 
state  accompanying  or  succeeding — and  in  every  instance  relieved  by  the 
discharge  of  wind  from  the  stomach ;  indeed  I  would  suggest  that  inde- 
gestion  or  gouty  tendency  producing  flatulence  may,  in  some  measure, 
excite  these  attacks.  Subject  to  uneasiness  in  the  stomach,  and  anxious 
hurried  sensation  and  feeling  of  distention,  with  a  noise  of  wind  passing 
from  side  to  side  about  the  region  of  the  navel  on  exerting  the  muscles, 
I  have  felt  relief  from  chewing  a  bit  of  ginger  and  swallowing  it,  wind 


542  CLINICAL   MEDICINE. 

immediately  coming  away.  All  these  annoyances  generally  vanisli  for 
some  time  after  an  attack  of  gout,  which  I  have  had  occasionally  in  the 
feet  at  intervals  of  twelve  or  fifteen  months.  Warm  baths  or  warm 
water  to  the  feet  always  bring  on  faintishness,  a  feverish  feel,  and  want  of 
rest ;  my  appetite  is  perfectly  good,  and  I  walk  four  or  five  miles  with- 
out any  fatigue,  as  my  general  allowance  of  exercise,  at  least  one  mile 
before  breakfast;  the  bowels  at  times  are  confined,  and  rest  disturbed  by 
dreams  and  sudden  awaking,  in  fact  "night  mare,'^  and  then  the 
stomach  continues  uneasy  till  wind  is  expelled. 

"  The  last  attack  of  insensibility  came  on  after  I  had  gone  to  sleep,  and 
I  doubt  whether  I  should  have  been  conscious  of  its  extent  had  I  been 
alone ;  the  following  day  I  found  one  eye  blackened,  and  a  black  mark 
or  bruise  on  the  thigh  near  the  hip-joint.  I  cried  out  on  the  attack 
commencing,  as  I  am  informed — this  was  the  28th  or  29th  of  January, 
and  my  bowels  had  been  very  irregular,  with  pain  and  uneasiness  low 
down,  griping  and  flatulence  to  a  considerable  extent.  After  this  at- 
tack I  felt  little  worse,  if  at  all,  on  the  following  days — the  tongue  had 
been  a  little  bitten  at  one  side  and  there  was  rather  a  stiff  and  cramped 
feel  in  the  legs.  The  opening  whence  the  bone  came  in  the  head  is 
kept  open  as  an  issue,  with  a  bean,  and  sometimes  becomes  inflamed 
and  painful,  and  may  perhaps  aggravate  the  stomach  uneasiness,  but 
the  application  of  lunar  caustic  relieves  this  in  general.  Before  the 
headache  commenced,  sea-bathing  and  swimming  agreed  particularly 
well,  but  any  application  of  cold  water  (except  to  the  head)  now  dis- 
agrees, but  I  use  it  daily  to  the  head  and  neck  by  sponging  before 
dressing  the  issue." 


543 


LECTURE  XXXVI. 

PARALYSIS. 

Having  recently  met  with  some  very  interesting  and  remarkable  cases 
of  impairment  of  the  muscular  functions  of  the  lower  extremities,  I 
am  anxious  to  offer  a  few  observations  on  paraplegia,  particularly  while 
the  subject  is  still  fresh  in  my  mind :  you  are  aware  that  by  paraplegia 
is  meant  that  species  of  paralysis  in  which  the  lower  extremities  are 
affected — a  paralysis  frequently  embracing  loss  of  motion  and  loss  of 
sensation  in  the  lower  extremities,  accompanied,  in  many  instances, 
with  derangement  of  the  muscular  power  of  the  bladder  and  rectum. 
Now,  I  wish  you  clearly  to  understand  that  it  is  not  my  intention  to 
describe  the  symptoms,  or  discuss  the  causes,  of  those  species  of  para- 
plegia which  are  well  ascertained,  and  of  which  you  will  find  satisfac- 
tory descriptions  in  your  books  :  under  this  head  may  be  classed  all 
those  cases  which  are  produced  by  disease  of  the  spinal  marrow,  its 
membranes,  the  vertebrae  or  their  ligaments,  and  diseases  directly 
affecting  the  great  nerves  which  supply  the  lower  extremities.  All 
these  matters  have  been  sufficiently  studied,  and  require  no  addi- 
tional observations  from  me;  my  object  is  to  elucidate  some  of  the 
obscurer  varieties  of  paraplegia.  I  have  in  the  last  lecture  but  two 
touched  on  this  topic,  but  I  have  since  met  with  many  cases,  and  made 
inquiries  which  tend  still  further  to  illustrate  the  subject.  Witliin  this 
last  month,  I  have  had  an  opportunity  of  witnessing  a  very  striking 
illustration  of  tlie  fact,  that  injury  affecting  one  branch  of  a  nerve  will 
be  propagated  by  a  retrograde  action,  so  as  to  affect  another  and  more 
distant  branch.  A  young  gentleman,  distinguished  for  the  extent  of 
his  classical  and  mathematical  acquirements,  and  who  had  just  succeeded 
in  obtaining  the  senior  moderatorship  (analogous  to  the  wranglersliip  of 
the  Enghsh  universities)  swallowed  a  small  but  angular  piece  of  chicken- 
bone.  It  lodged  low  down  in  the  oesophagus,  and  was  not  pushed,  by 
means  of  a  probang,  into  the  stomach  until  after  the  lapse  of  more 


tj4i4!  CLINICAL   MEDICINE. 

than  an  hour.  Considerable  inflammation  of  the  pharynx,  oesophagus, 
and  surrounding  tissues  was  the  consequence ;  on  the  third  day  of  his 
illness  he  got  a  violent,  long-continued,  and  ague-like  rigor,  which  ter- 
minated in  a  profuse  perspiration,  and  ushered  in  a  well-marked  inflam- 
mation of  the  neck  of  the  bladder. 

We  also  find  that  impressions  afl'ecting  the  frontal  branches  of  the 
fifth  nerve  may,  by  a  reflex  action,  operate  on  the  retina  so  as  to  cause 
blindness.  Here  the  morbid  action  travels  from  the  circumference 
towards  the  centre,  and  is  again  reflected  towards  the  circumference  so 
as  to  affect  a  separate  and  distinct  part.  Of  this  I  lately  saw  a  curious 
and  instructive  example.  A  medical  student,  travelling  through  Wales 
on  the  outside  of  the  mail,  was  exposed  for  many  hours  to  a  keen 
north-easterly  wind  blowing  directly  in  his  face.  When  he  arrived  at 
the  end  of  his  journey,  he  found  that  his  vision  was  impaired,  and  that 
every  thing  seemed  as  if  he  was  looking  through  a  gauze  veil.  There 
was  no  headache,  no  symptom  of  indigestion,  to  account  for  this  evi- 
dently slight  degree  of  amaurosis,  and  yet  he  was  recommended  to  use 
cupping  to  the  nape  of  the  neck,  and  strong  purgatives.  When  he 
consulted  me,  which  he  did  in  the  course  of  a  few  days  afterwards,  'I 
at  once  saw  that  there  was  something  unusual  in  the  case ;  and,  after  a 
careful  examination,  I  at  length  elicited  from  him  the  fact  of  his  having 
been  exposed  to  the  influence  of  the  cold  wind.  It  was  now  apparent 
that  the  retina  suffered  in  consequence  of  an  impression  made  on  the 
facial  branches  of  the  fifth  pair.  The  cure  was  effected,  not  by  a  treat- 
ment directed  to  relieve  cerebral  congestion,  but  by  stimulation  of  the 
skin  of  the  face,  forehead,  temples,  &c. 

It  is,  however,  unnecessary  to  multiply  examples  to  prove  the  truth  of 
the  proposition,  that  disease  may  commence  in  one  portion  of  the  ner- 
vous extremities,  and  be  propagated  towards  the  centre,  and  hence,  by 
a  reflex  action,  to  other  and  distant  parts.  Bearing  this  in  mind,  we 
can  explain  why  it  is  that  disease  commencing  in  one  part  of  the  sys- 
tem may  produce  morbid  action  in  another  and  distant  part ;  and  it 
certainly  appears  strange,  that,  with  so  many  striking  examples  before 
them,  pathologists  should  have  so  long  overlooked  this  cause,  when 
seeking  to  explain  the  nature  of  many  forms  of  paralysis.  If  certain 
irritations  of  the  nervous  extremities  in  one  part  of  the  body  are  capa- 
ble of  giving  rise  to  a  derangement  in  the  whole  system  of  voluntary 
muscles ;  if  a  local  affection  may  become  the  cause  of  exalting  and  ren- 
dering irregular  the  functions  of  every  muscle  in  the  body ;  then,  surely, 
it  is  not  difficult  to  conceive  that  a  cause,  local  as  the  former,  and  tend- 
ing not  to  exalt  but  to  depress  the  motor  function  of  the  muscles,  may 
likewise  affect  not  merely  the  nerves  and  muscles  of  the  part,  but  also 
those  of  the  whole  body,  or  of  distant  organs,  giving  rise  to  paralysis. 


PARAPLEGIA.  545 

Now,  pathologists  have  long  recognised  the  fact  that  general  muscular 
excitement  and  spasm  may  arise  from  the  operation  of  a  local  irritation. 
A  man  gets  a  contused  wound  on  his  thumb,  or  one  of  his  fingers,  and 
some  superficial  nerves  are  ii^jured.  In  the  course  of  a  few  days  he 
begins  to  feel  a  degree  of  stiffness  about  the  lower  jaw  and  muscles  of 
the  neck,  accompanied  by  a  sense  of  constriction  about  the  diaphragm. 
This  increases  gradually,  all  the  muscles  are  thrown  into  a  state  of  fixed 
spasm,  and  he  gets  tetanus.  Here  a  few  trifling  branches  of  the  digital 
nerves  are  injured,  the  morbid  action  is  conveyed  from  them  along  tlie 
nerves  of  the  arm  to  the  spinal  cord  and  brain,  and  is  thence,  by  a  reflex 
action,  propagated  all  over  the  body.  A  wound  in  the  finger  causes  a 
morbid  action  in  its  nerves,  and  it  has  been  acknowledged  by  patholo- 
gists, that  this  by  acting  on  the  brain  and  spinal  cord,  may  give  rise  to 
a  general  morbid  action  of  the  muscular  system.  This  being  the  case, 
there  is  nothing  improbable  in  supposing  that  a  cause  affecting  any  por- 
tion of  the  branches  of  the  nervous  tree,  and  which  produces  effects  of 
a  paralytic  nature,  may  likewise  re-act  backwards  towards  the  nervous 
centres,  and  thence,  by  a  reflex  progress,  may  extend  its  influence  to 
distant  parts  of  the  circumference. 

To  give  another  instance  :  how  often  do  we  see  irritation,  commencing 
in  the  intestinal  mucous  membrane,  propagated  backwards  towards  the 
brain  ?  Take  the  familiar  example  of  intestinal  worms.  A  child  labours 
under  worms;  here  the  irritation  of  the  digestive  mucous  surface, 
whether  it  be  produced  by  the  worms,  or  by  the  indigestion  which 
accompanies  them,  is  propagated  from  the  stomach  and  bowels  to  the 
brain,  and  thence  reflected  to  the  voluntary  muscles,  causing  general 
convulsions. 

Dr.  Stokes  details  the  following  case  in  his  lectures :  "  A  young 
woman  was  admitted  into  one  of  the  surgical  wards  of  the  Meath  Hos- 
pital, for  some  injury  of  a  trivial  nature.  While  in  tlie  hospital  she  got 
feverish  symptoms,  which  were  treated  with  purgatives,  consisting  of 
calomel,  jalap,  and  the  hlach  hotthj  a  remedy  which  deserves  the  name 
of  coffin  bottle,  perhaps  better  than  the  pectoral  mixture  so  liberally 
dealt  out  in  our  dispensaries  as  a  cure  for  all  cases  of  pulmonary  disease. 
She  was  violently  purged,  the  symptoms  of  fever  subsided,  and  she  was 
discharged.  A  few  days  afterwards,  her  mother  applied  to  have  her  re- 
admitted, and  she  was  brought  in  again,  and  placed  in  one  of  the  medical 
w^ards.  Her  state  on  admission  was  as  follows  : — She  had  fever,  pain 
in  the  head,  violent  contractions  in  the  fingers,  and  alternate  contraction 
and  extension  of  the  wrist  and  fore-arm.  These  muscular  spasms  were 
so  great,  that  the  strongest  man  could  scarcely  control  the  motions  of 
the  left  fore-arm.  In  addition  to  these  symptoms,  she  had  slight  thirst, 
VOL.  I.  B5 


546  CLINICAL   MEDICINE. 

some  diarrhoea,  but  no  abdominal  tenderness.  On  this  occasion  a  double 
plan  of  treatment  was  pursued,  the  therapeutic  means  being  directed  to 
the  head,  in  consequence  of  the  marked  symptoms  of  local  disease  of  the 
brain,  and  to  the  belly,  from  the  circumstance  of  abdominal  derange- 
ment observed  in  this  and  her  former  illness. 

''  She  died  shortly  afterwards  with  violent  spasms  of  the  head  and 
fore-arm ;  and  as  she  had  presented  all  the  ordinary  symptoms  of  a  local 
inflammation  of  the  opposite  side  of  the  brain,  we  naturally  looked  there 
first  for  the  seat  of  the  disease.  After  a  careful  examination,  however, 
no  perceptible  trace  of  disease  could  be  found  in  the  substance  of  the 
brain,  which  appeared  all  throughout  remarkably  healthy.  She  had  all  the 
symptoms  which,  according  to  Serres  and  Toville,  would  indicate  disease 
of  the  optic  thalamus  or  posterior  lobe  of  the  opposite  side,  yet  we  could 
not  find  any  lesion  whatever  of  its  substance,  after  the  most  careful 
examination.  But  on  opening  the  abdomen,  we  found  evident  marks  of 
disease ;  the  lower  third  of  the  ileum j  for  the  length  of  six  or  eight 
inches,  was  one  unbroken  sheet  of  recent  ulcerations."  This  case,  gen- 
tlemen, you  will  perceive  just  now,  bears  very  strongly  on  the  subject  of 
paraplegia  arising  from  enteritis. 

Again  :  how  often  do  we  see  convulsions  brought  on  in  the  same  way 
by  cutaneous  irritation  ?  A  child  gets  an  attack  of  fever,  accompanied 
by  general  irritability  and  restlessness.  During  the  course  of  the  dis- 
ease, the  lungs  become  ajffected,  and  the  medical  attendant  applies  a 
large  blister,  which  is  left  on  for  several  hours.  Next  day  the  symptoms 
of  nervous  irritation  become  more  violent ;  the  child  is  perfectly  restless, 
or,  if  it  dozes  for  a  moment,  awakes  screaming,  and  is  finally  attacked 
with  general  convulsions.  Many  other  examples  could  be  brought  to 
support  this  view  of  the  question,  and  prove  that  morbidly  increased 
action  of  the  whole  muscular  system  may  be  excited  by  a  cause  acting 
merely  on  some  insulated  portion  of  the  nervous  extremities. 

I  think,  therefore,  that  I  am  borne  out  by  analogies  strikingly  exhi- 
bited by  numberless  examples,  in  asserting  that  the  circumference  of  the 
nervous  system  has  been  too  much  neglected  by  pathologists  in  their 
explanations  of  the  nature  and  causes  of  paralytic  affections.  I  have 
given  before  instances  of  pains  commencing  in  particular  parts  of  the 
body,  and  travelling  back  towards  the  spine,  so  as  to  give  rise  to  an 
affection  of  that  organ,  which  has  been  too  generally  looked  upon  as  the 
result  of  idiopathic  disease.  How  often  does  this  happen  in  hysteria  ? 
How  often  does  it  occur,  that  the  organ  primarily  engaged  in  hysterical 
cases  becomes,  during  the  attacks,  acutely  painful,  and  as  the  disease 
proceeds,  the  pain  travels  back  towards  the  spine,  until  at  length,  the 
spinal  cord  itself  becomes  affected,  and  we  find  acute  pain  and  tenderness 


PARAPLEGIA.  547 

over  some  portion  of  its  track  ?  I  am  fully  persuaded  that  many 
modern  authors,  who  have  ascribed  the  phenomena  of  hysteria  and 
other  affections  to  spinal  irritation,  have  been  too  hasty  and  indiscrim- 
inate in  their  explanations.  In  the  majority  of  cases,  you  will  find 
hysteric  patients  complain  at  first,  not  of  pain  in  any  part  of  the  spinal 
cord,  but  in  the  right  side  in  the  situation  of  the  Hver,  in  the  region  of 
the  heart  or  stomach,  or  in  the  head,  or  the  pelvic  region.  At  this 
period  there  is  seldom  any  tenderness  over  the  spinal  cord ;  but,  as  the 
disease  goes  on,  the  irritation  which  existed  in  some  of  the  situations 
to  which  I  have  referred,  is  extended  to  the  spine,  and  pain  and  tender- 
ness are  now  felt  over  some  of  the  spinous  processes  of  the  vertebrae. 
When  this  has  taken  place,  then  the  spinal  irritation  thus  produced 
becomes  itself  a  new  cause  of  disease,  from  which,  as  a  centre,  the 
morbid  influence  is  propagated  to  other  organs.  The  profession  owes 
much  to  Teale,  Griffin,  and  other  writers,  who  have  pointed  out  the  im- 
portance of  attending  to  this  spinal  tenderness  in  cases  of  hysteria,  &c. 
Still,  however,  like  all  those  who  have  been  employed  in  investigating  a 
new  subject,  they  have,  perhaps,  generalised  too  hastily,  and  have,  in 
many  cases,  regarded  this  spinal  tenderness  as  a  cause,  when  it  should 
have  been  merely  considered  as  a  consequence. 

Having  now  endeavoured  to  explain  some  of  the  general  principles 
which  should  guide  us  in  the  investigation  of  nervous  diseases,  I  shall 
relate  some  cases  of  paraplegia,  which,  though  differing  in  their  origin 
as  to  the  organ  inflamed,  will  strike  you  as  exhibiting  a  close  analogy 
to  those  published  by  Mr.  Stanley. 

In  November,  1832,  I  attended,  with  Mr.  Kirby  and  Mr.  Cusack,  a 
young  gentleman,  aged  fourteen,  who  was  residing  at  a  boarding  school 
in  the  vicinity  of  Dublin,  and  whose  case  I  before  cursorily  referred  to. 
He  had  eaten  a  large  quantity  of  nuts  on  the  eve  of  Allhallows,  and 
had,  in  consequence,  obstruction  of  the  bowels,  attended  with  sense  of 
weight  and  pain  of  the  stomach,  nausea,  loss  of  appetite,  and  obstinate 
constipation.  Active  purgatives  of  different  kinds  were  employed 
without  effect,  and  the  obstruction  was  only  removed  by  the  use  of 
repeated  enemata,  thrown  up  with  Eead^s  syringe,  introduced  as  far  into 
the  cavity  of  the  intestine  a^  the  circumstances  of  the  case  permitted. 
To  these  means,  assisted  by  leeching  and  stuping,  the  constipation 
yielded ;  but  its  removal  was  followed  by  symptoms  of  enteric  inflam- 
mation, embracing  not  one,  but  all  the  coats  of  the  intestine — the 
mucous,  the  muscular,  and  certainly  the  peritoneal.  The  occurrence  of 
a  new  and  violent  disease  greatly  impeded  his  cure ;  we  had  a  long  and 
anxious  attendance,  and  the  young  gentleman  escaped  with  great  diffi- 
culty.    However,  the  enteric  symptoms  at  length  gave  way,   convales- 


548  CLINICAL   MEDICINE. 

cence  became  manifestly  established,  the  patient  was  able  to  sit  up  in 
his  bed,  and  as  his  strengtli  and  appetite  were  rapidly  returning,  he  was 
informed  that  he  might  get  up.  On  attempting  to  leave  his  bed,  it 
was  found  that  he  had  lost  the  power  of  using  his  lower  extremities — 
in  fact,  he  had  become  paraplegic.  He  had  perfect  power  over  his  arms 
and  trunk,  but  the  lower  extremities  were  quite  useless.  The  paralysis, 
however,  was  entirely  limited  to  the  muscles ;  there  was  no  diminution 
of  sensibiHty  in  the  limbs ;  no  numbness,  pain,  or  sensation  of  formi- 
cation ;  and  the  muscular  functions  of  the  bladder  and  rectum  were, 
apparently,  uninjured. 

Before  I  enter  on  the  explanation  of  this  case,  permit  me  to  recite 
the  following  : — I  was  called  to  visit  a  lady  residing  in  the  neighbour- 
hood of  Merrion-square  who  was  said  to  be  labouring  under  symptoms 
of  dyspepsia.  She  had  a  sense  of  weight  about  the  stomach,  nausea, 
tendency  to  vomit,  epigastric  and  hypochondriac  tenderness — the  latter 
situated  on  the  right  side,  but  no  fever  nor  excitement  of  the  circula- 
tion. In  the  course  of  two  or  three  days,  she  became  slightly  jaun- 
diced, and  it  was  evident  that  the  latent  cause  of  her  disease  was,  in  all 
probability,  a  gastro-duodenitis  terminating  in  an  affection  of  the  liver. 
It  is  sufficient  to  say,  that  this  lady's  symptoms  went  on,  and  that  the 
diseased  action  gradually  extended  to  the  whole  intestinal  tube,  liver, 
and  peritoneum.  Her  bowels  became  tympanitic,  her  belly  extremely 
tender  on  pressure,  she  got  low  fever,  with  quick  pulse  and  great  rest- 
lessness, and  was  saved  with  difficulty  by  the  repeated  appKcation  of 
leeches,  and  the  use  of  calomel,  so  as  to  afiect  the  mouth.  She 
became  convalescent ;  but  with  the  return  of  health,  it  was  found  that 
she  had  lost  the  power  of  using  her  lower  extremities,  and  she  con- 
tinued paraplegic  for  a  long  time. 

In  the  case  of  the  young  gentleman  already  detailed,  you  will  recol- 
lect that  the  paralysis  was  entirely  limited  to  the  muscular  functions  of 
the  lower  hmbs,  and  that  there  was  no  derangement  of  sensation,  no 
lesion  of  the  muscular  powers  of  the  rectum  or  bladder.  The  same 
thing  occurred  in  this  case.  There  was  in  the  beginning  no  impair- 
ment of  sensibility,  and  the  power  over  the  rectum  and  bladder  was 
uninjured.  Soon  afterwards,  however,  she  complained  of  pain  in  the 
loins  and  bowels,  and  the  muscular  functions  of  the  bladder  became 
deranged.  Indeed,  the  case  was  then  unfavourable ;  it  had  resisted  the 
ordinary  remedies,  and  threatened  to  become  one  of  confirmed  para- 
plegia, but  she  began  to  improve  in  about  six  months,  and  eventually 
recovered  completely.  It  is  to  be  observed,  that  in  this  lady  the  loss 
of  power  was  much  more  complete  than  in  the  young  gentleman  before 
referred  to ;  his  paraplegia  was  by  no  means  perfect,  and  yielded  to  the 


PABAPLEGIA.  549 

employment  of  stimulating  frictions  to  the  extremities,  combined  with 
a  cautious  use  of  internal  stimulants  and  tonics.  In  neither  of  these 
cases  was  the  loss  of  muscular  power  so  great  as  to  deprive  the  patients 
of  the  use  of  their  legs  while  lying  in  bed.  They  could  then  be  raised, 
flexed,  and  extended  with  apparent  ease  and  strength ;  and  yet,  when 
the  patient  attempted  to  stand  up  or  walk,  he  was  totally  unable  to  do 
either,  his  legs  sinking  under  him ;  and  even  when  supported  by  a  per- 
son on  each  side,  so  as  to  take  the  greater  part  of  the  weight  of  the 
body  ojff  the  Hmbs,  he  was  still  unable  to  advance  one  foot  before 
another.  I  cannot  understand  why  so  great  a  difference  should  exist 
between  the  muscular  force  of  the  legs  in  the  one  position  and  in  the 
other. 

Here,  you  perceive,  we  have  more  or  less  complete  loss  of  power  of 
the  lower  extremities,  supervening  on  inflammation  of  the  gastro-intes- 
tinal  mucous  surface.  Of  this  I  have  now  witnessed  several  examples. 
How  are  we  to  account  for  this  ?  In  what  way  does  paraplegia  arise 
from  inflammation  of  the  bowels  ? 

The  mode  in  which  I  would  explain  this  phenomenon  is  as  follows : — • 
The  impression  made  by  inflammatory  derangement  on  the  nervous 
filaments  distributed  to  the  mucous  coat  of  the  intestines  is  propagated 
to  the  spinal  cord,  and  from  this  re-acts  on  the  muscular  functions  of 
the  lower  extremities.  It  is  true  that  the  intestines,  and  most  of  the 
abdominal  organs,  are  ahnost  exclusively  supplied  with  nerves  from  the 
great  sympathetic ;  but  you  are  to  recollect  that  these  communicate  by 
numerous  branches  with  the  spinal  nerves,  and  that,  consequently, 
morbid  impressions  made  on  their  extremities  may  be  rapidly  and  ex- 
tensively propagated  to  the  spinal  cord,  and  from  thence  by  a  reflex 
action  to  the  muscular  nerves  of  the  lower  extremities.  When  I  first 
met  with  cases  of  paraplegia  after  inflammation  of  the  bowels,  or  fever 
with  gastro-enteric  symptoms,  I  thought  that,  owing  to  some  peculiarity 
in  the  case,  the  great  lumbar  nerves  had  become  implicated  in  the  dis- 
ease ;  that  there  was  an  actual  inflammatory  state  of  the  neurilema, 
accompanied  by  thickening  and  efiusion,  which,  by  compressing  the 
nervous  matter,  gave  rise  to  the  paraplegic  symptoms.  A  more  exten- 
sive review  of  the  subject,  however,  has  convinced  me  that  this  is  not 
the  fact ;  for,  if  it  were,  the  affection  of  the  nerves  would  naturally  be 
attended  with  acute  pains  shooting  in  the  direction  of  their  course — - 
for,  as  far  as  my  experience  goes,  in  every  instance  of  inflammation 
attacking  the  neurilema,  intense  pain  is  felt  in  the  parts  to  which  the. 
branches  of  the  affected  nerve  are  distributed. 

Again,  though  this  explanation  might  apply  to  cases  in  which  the 
inflammation  was  general — as  where  enteric  is  combined  with  peritoneal 


550  CLINICAL  MEDICINE. 

inflammation — ^it  would  not  apply  to  those  cases  in  which  the  inflam- 
matory action  is  localised.  Thus,  in  Mr.  Stanley's  cases,  the  paraplegia 
supervened  on  inflammation  principally  limited  to  the  kidneys.  In 
seven  cases  detailed  in  Mr.  Stanley's  paper"^,  we  find  paralytic  symp- 
toms produced,  not  by  any  derangement  commencing  in  the  brain  or 
spinal  cord,  but  in  consequence  of  an  irritation  having  its  seat  and 
origin  in  the  kidneys ;  and  yet,  in  the  majority  of  his  patients,  the  para- 
plegia was  as  complete  as  if  it  had  been  produced  by  idiopathic  disease 
of  the  cord  or  its  investments.  What  was  equally  remarkable,  many  of 
these  cases  were  accompanied  by  spinal  tenderness ;  so  that  the  most 
experienced  practitioners,  on  a  review  of  the  symptoms,  were  inclined 
to  look  upon  them  as  cases  of  disease  afi'ecting  the  vertebrse,  or  the 
spinal  cord  and  its  sheath.  Yet  on  dissection  there  was  no  caries  of 
the  bones;  no  destruction  of  ligaments;  no  remarkable  vascularity, 
softening,  or  suppuration  of  the  spinal  cord ;  no  inflammation  of  its 
membranes,  or  effusion  in  its  sheath.  In  almost  all,  the  morbid  pheno- 
mena were  confined  to  the  kidneys ;  there  were  depositions  of  pus  dis- 
persed through  their  substance,  and  the  mucous  lining  of  the  infun- 
dibula,  ureters,  and  bladder,  was  thickened  and  vascular.  The  forma- 
tion of  purulent  matter  was  not,  however,  connected  with  the  paraple- 
gia further  than  as  being,  like  it,  produced  by  the  same  cause — inflam- 
mation of  the  kidney.  In  one  case  the  paraplegia  was  very  complete, 
and  the  inflammation  of  the  kidney  had  not  advanced  to  the  stage  of 
suppuration. 

There  can  be  little  doubt  that  others  have  frequently  noticed  the 
occurrence  of  paraplegia  after  inflammation  of  the  bowels,  although  no 
author  has  as  yet  written  upon  the  subject.  It  is  well  to  be  acquainted 
with  the  occasional  occurrence  of  so  untoward  and  obstinate  a  sequela 
of  enteric  inflammation,  in  order  that  we  may  watch  attentively  the 
state  of  the  lower  extremities  immediately  after  the  inflammation  of  the 
bowels  has  been  subdued.  As  the  patient,  in  such  cases,  has  no  pains 
in  his  limbs,  and  is  not  conscious  of  any  loss  of  power  until  he  attempts 
to  stand  up — and  as  this  attempt  is  not  usually  made  for  many  days 
after  the  subsidence  of  the  inflammation  of  the  bowels,  in  consequence 
of  the  great  debility  which  the  disease  and  the  active  treatment  neces- 
sarily resorted  to  produce — this  variety  of  paraplegia  is  very  liable  to  be 
overlooked  in  its  commencement,  and  is  thus  neglected  at  the  very 
period  when  treatment  is  most  likely  to  prove  beneficial. 

The  foregoing  observations  have,  no  doubt,  excited  a  suspicion  in  the 
minds  of  some  of  you,  that  the  paralysis  so  often  observed  to  follow 

•  Medico- Chirurgical  Transactions,  vol.  xviii.  p.  260. 


PARAPLEGIA.  551 

painter's  colic  may  be  derived  from  a  reaction  of  tlie  nervous  system  of 
the  bowels  on  that  of  the  muscular  system  in  general.  Dr.  Bright,  in- 
deed, has  asserted  that  inflammation  of  the  spinal  marrow  or  sheath,  as 
denoted  by  spinal  tenderness,  always  precedes  the  paralysis  produced  by 
lead.  It  often  does,  but  by  no  means  constantly ;  for  I  have  pointed 
out  to  you  several  cases  in  this  hospital  in  which  not  the  slightest  ves- 
tige of  spinal  tenderness  could  be  detected  either  before  the  commence- 
ment, or  during  the  progress,  of  the  paralysis  which  so  often  follows 
painter's  colic.  I  am  not  inclined  to  adopt  the  supposition  that  the 
paralysis  in  such  cases  is  merely  secondary,  and  the  result  of  the  intes- 
tinal irritation.  I  think  it  much  more  probable  that  it  depends  on  the 
poisonous  efi'ects  of  the  lead  acting  directly  on  the  nervous  system.  The 
same  observation  applies  to  the  paralysis  which  so  often  occurs  as  a 
result  of  large  doses  of  arsenic.  Orfila  has  remarked  that  some  of  the 
dogs  he  experimented  on,  and  which  narrowly  escaped  dying  in  conse- 
quence of  large  doses  of  arsenic,  became,  when  they  recovered  from  the 
immediate  effects  of  the  poison,  permanently  paraplegic.  I  look  upon 
this  paralysis  as  a  direct  consequence  of  the  deleterious  action  of  the 
arsenic  on  the  nervous  system,  and  not  as  the  result  of  the  gastro- 
enteritis it  invariably  produces.  The  fact,  however,  is  well  worthy  of 
attention,  that  both  arsenic  and  lead  produce  intestinal  irritation  in  the 
first  instance,  and  loss  of  muscular  power  in  the  second.  A  knowledge 
of  this  fact  will  prepare  us  for  understanding  the  connexion  which 
appears  to  exist  between  intestinal  irritation  and  paralysis. 

In  a  lecture  published  by  Dr.  Stokes,  in  the  London  Medical  and 
Surgical  Journal y  he  makes  the  following  observations  : — *'  Here, 
then,  we  have  well-marked  paraplegia  without  any  perceptible  or- 
ganic change  in  the  spinal  cord  or  its  investments,  but  presenting 
distinct  traces  of  disease  in  the  kidneys.  This  leads  me  to  observe 
the  very  close  connexion  which  exists  between  the  kidneys  and 
spinal  cord — a  connexion  which  has  been  long  recognized  by  medical 
practitioners,  but  only  in  a  limited  point  of  view ;  for,  though  they 
were  of  opinion  that  disease  of  the  kidneys  and  a  discharge  of  ammo- 
niacal  urine  were  the  results  of  spinal  disease,  they  never  seem  to  have 
reflected  that  the  reverse  of  this  might  happen.  It  seems,  however, 
now  to  be  almost  completely  established,  that  disease  of  the  kidneys 
may  produce  symptoms  which  are  referable  to  disease  of  the  spine. 
Medical  men  have  been  too  much  in  the  habit  of  looking  at  this  matter 
only  in  one  point  of  view.  They  know  that  disease  of  the  spine  will 
produce  disease  of  the  kidneys,  and  here  they  stop ;  but  it  has  been 
shown  that  the  reverse  of  this  may  happen,  and  that  renal  disease  may 
produce  very  remarkable  lesions  in  the  functions  of  the  spine.     Of  this 


OOX  CLINICAL   MEDICINE. 

very  curious  occurreuce  we  have  many  analogies  in  pathology.  Thus, 
for  instance,  in  several  cases  of  cerebral  disease,  but  particularly  in 
hydrocephalus,  we  have  vomiting ;  here  we  have  functional  disease  of 
the  stomach  depending  on  disease  of  the  brain.  Take  the  reverse  of 
this, — observe  the  dehrium  which  attends  a  case  of  gastro-enteritis ; 
here  you  have  the  functions  of  the  brain  deranged  in  a  most  remarkable 
manner,  and  this  produced  by  sympathy  with  an  inflamed  mucous  mem- 
brane. The  truth  is,  that  in  the  spine  and  kidney,  as  well  as  in  various 
parts  of  the  body,  we  may  have  two  organs  so  closely  connected  in 
sympathy,  that  disease  of  the  one  will  bring  on  serious  functional  lesion 
of  the  other." 

It  will  be  seen  that  these  observations  coincide,  in  many  points,  with 
the  principles  I  have  laid  down  in  my  lecture  on  the  subject  of  nervous 
pathology.  On  this  point  Mr.  Stanley  makes  the  following  remarks  : — 
"  In  reflecting  on  the  phenomena  of  the  first  series  of  cases  which  have 
been  detailed  in  this  paper  it  might  be  thought  improbable  that  irritation, 
commencing  in  the  kidney  or  in  the  bladder,  should  be  propagated 
through  sentient  nerves  to  the  spinal  cord,  and  that  the  impression 
should  thence  be  transmitted  through  both  the  motive  and  sentient 
spinal  nerves  to  the  limbs — here  occasioning  an  impairment  both  of 
sensation  and  the  power  of  motion.  Some  illustration  of  this  subject 
seems  to  be  furnished  by  the  researches  of  experimental  physiology. 
If,  in  an  animal,  '  a  few  seconds  after  it  has  been  deprived  of  life,  the 
spinal  cord  be  then  divided  in  the  middle  of  the  neck,  and  again  in  the 
middle  of  the  back,  upon  irritating  a  sentient  organ  connected  with 
either  isolated  segment,  muscular  action  is  produced — that  is  to  say,  a 
sentient  organ  is  excited — and  an  irritation  is  propagated  through  the 
sentient  nerve  to  tlie  isolated  segment  of  the  spinal  marrow,  where  it 
gives  rise  to  some  change,  which  is  followed  by  an  impulse  along  the 
voluntary  nerves  to  the  muscles  of  the  part.'"^  In  the  instances  which 
have  been  adduced,  irritation,  commencing  in  the  nerves  of  an  internal 
organ — the  kidney — has  been  transmitted  through  the  spinal  cord  to 
the  motive  and  sentient  nerves  of  the  lower  extremities ;  but  the  same 
phenomena  may  occur  in  an  opposite  order,  as  in  the  case  of  a  com- 
pound fracture  or  other  severe  injury  of  the  lower  extremity,  followed 
by  retention  of  urine  from  irritation  arising  in  the  anterior  crural  and 
ischiatic  nerves,  and  communicated  through  the  lumbar  and  sacral 
plexuses  of  spinal  nerves  to  the  nerves  of  the  bladder.  Extending 
these  views  to  cases  of  neuralgia  where  there  is  no  visible  derangement 
of  structure  or  other  local  cause  of  excitement,  it  will  always  be  diffi- 

*  Outlines  of  Human  Physiology,  by  H.  Mayo. 


PARAPLEGIA.  553 

cult  to  determine  whether  the  source  of  irritation  be  in  the  affected 
nerves,  or  in  the  central  portion  of  the  nervous  system  whence  they  are 
derived/' 

You  will  perceive  that  this  explanation,  as  far  as  it  goes,  though  not 
in  the  same  words,  is  in  meaning  the  same  as  that  which  I  have  given, 
with  this  exception — that  it  is  only  a  corollary  of  the  general  principles 
which  I  had  laid  down  in  my  lectures  on  the  pathology  of  the  nervous 
system.  Long  before  the  publication  of  Mr.  Stanle/s  paper,  I  had 
established  the  proposition  that  impressions  made  upon  any  portion  of 
the  nervous  extremities  may  be  propagated  towards  their  centres,  and 
thence  by  a  reflex  action  transmitted  to  the  nerves  of  other  and  distant 
parts,  so  as  to  give  rise  to  morbid  phenomena  analogous  to  those 
which  are  produced  by  disease  originating  in  the  central  parts  them- 
selves. Applying  this  principle  to  the  subject  of  paraplegia,  we  shall 
find  that,  independently  of  cerebral  or  spinal  disease,  it  may  arise  from 
a  variety  of  causes,  each  referable  to  lesions  commencing  in  distinct  and 
isolated  portions  of  the  nervous  extremities. 

Thus,  in  Mr.  Stanle/s  cases,  the  exciting  cause  seems  to  have  origi- 
nated in  the  urinary  system ;  in  the  case  which  I  have  detailed,  where 
it  supervened  on  inflammation  of  the  bowels,  it  commenced  in  the 
digestive — and  it  appears  from  a  communication  made  to  Mr.  Stanley  by 
Mr.  Hunt,  of  Dartmouth,  that  the  same  thing  may  result  from  irritation 
existing  in  the  uterine — system.  Mr.  Hunt  alludes  to  several  cases  of 
disease  of  the  uterus  being  followed  by  such  loss  of  power  in  the  lower 
limbs,  that  the  patients  were  entirely  confined  to  bed ;  adding  that  there 
was  no  change  of  structure  in  the  parts  to  which  the  symptoms  referred 
as  the  source  of  irritation.  In  addition  to  these,  I  shall  in  my  next 
lecture  bring  forward  several  cases  to  prove  that  a  similar  loss  of  power 
may  be  produced  by  the  action  of  cold  on  the  lower  extremities.  Indeed, 
the  number  of  cases  which  I  have  recently  met  with,  where  paraplegia 
was  evidently  brought  on  by  exposing  the  lower  extremities  to  cold  and 
wet,  has  very  strongly  directed  my  attention  to  this  form  of  the  dis- 
ease ;  and  I  trust  I  shall  be  able,  at  our  meeting,  to  communicate  some 
very  interesting  matter  on  the  subject. 


554 


LECTUEE  XXXVII. 


PARALYSIS. 


I  SHALL  commence  tliis  lecture  by  reading  the  following  case  bearing 
on  the  subject  we  were  last  engaged  considering,  for  which  I  am  indebted 
to  the  kindness  of  Dr.  Hutton. 

"  Richard  M'Nab,  a  sailor,  aged  thirty-eight,  was  admitted  into  the 
Richmond  Hospital  on  the  ]6th  of  January,  1835,  and  placed  under 
Dr.  Hutton's  care.  His  previous  history  was  briefly  as  follows : — In 
the  summer  of  1826  he  strained  his  back  in  leaping,  and  was  confined 
to  bed  in  consequence  of  the  accident,  but  recovered  in  about  twelve 
days.  Shortly  afterwards  he  contracted  gonorrhoea,  which  was  attended 
with  hernia  humoralis ;  this  yielded  to  repeated  local  bleeding,  but  a 
gleet  remained,  and  this,  after  continuing  for  some  time,  disappeared 
under  the  use  of  sea-bathing.  He  then  enjoyed  good  health,  with  the 
exception  of  occasional  slight  pain  in  the  lumbar  region,  until  October, 
1830,  when  being  much  exposed  to  cold  and  wet  during  a  long  and 
fatiguing  voyage,  he  got  an  attack  of  piles,  for  which  he  was  under 
medical  treatment  for  seven  months.  During  the  continuance  of  this 
affection,  he  first  observed  a  frequency  in  micturition,  but  had  no  reten- 
tion or  sensible  obstruction  of  urine. 

After  recovering  from  the  hemorrhoidal  attack,  he  enjoyed  good  health 
nntil  September,  1834,  when  coming  from  Cadiz  to  the  port  of  Dublin 
in  a  very  leaky  vessel,  he  suffered  greatly  from  cold,  wet,  and  fatigue- 
being  almost  constantly  engaged  at  the  pumps,  which  could  not  be  left 
for  ten  minutes  at  a  time.  In  addition  to  this,  being  deprived  of  his 
usual  allowance  of  spirits  for  thirty-two  days,  he  found  himself,  on  his 
arrival  in  Dubhn,  in  a  very  weak  state.  He  rested  from  his  occupation 
for  a  fortnight  after  discharging  his  cargo,  and  states  that  during  this  time 
he  drank  from  four  to  six  glasses  of  whiskey  daily.  He  then  went  on 
board  the  Elizabeth,  of  London,  as  chief  mate,  but  after  eight  or  nine  days 
his  back  and  lower  extremities  became  affected  with  pain  and  weakness. 


PARAPLEGIA.  555 

which  increased  to  such  a  degree  that  he  was  obliged  to  give  up  his 
occupation  on  the  thirteenth  day.  He  states  that,  during  the  time  his 
back  and  legs  were  getting  weak,  he  was  obliged  to  pass  water  about 
three  times  in  an  hour,  which  he  did  with  pain  and  tenesmus.  On  the 
1st  of  January  the  pain  of  his  back  was  very  severe,  and  he  lost  the 
use  of  his  limbs,  but  not  completely,  for  he  could  support  himself,  and 
even  walked  a  little  with  the  aid  of  two  sticks. 

"  At  the  time  of  his  admission  he  appeared  somewhat  broken  down 
in  his  general  health ;  he  was  pale,  emaciated,  and  laboured  under  de- 
rangement of  his  digestive  organs.  He  suffered  from  occasional  chills, 
succeeded  by  heats  and  sweating,  which  occurred  at  irregular  periods ; 
he  also  laboured  under  incontinence  of  urine  and  dysuria,  and  the  stream 
of  urine  was  much  diminished  :  weakness  and  loss  of  power  in  his  lower 
extremities  as  reported. 

"  His  treatment  was  as  follows  : — First,  cupping  over  the  loins,  then 
moxse  in  the  same  situation ;  attention  to  his  digestive  organs ;  diluents 
and  opiates  for  the  urethral  symptoms.  On  the  26th  of  the  same 
month,  a  very  close  stricture  was  found  to  exist  in  the  membranous 
portion  of  the  urethra.  A  small  catgut  bougie  of  double  length  was 
introduced,  so  that  one  half  of  it  projected  from  the  meatus ;  over  this 
was  slided  a  small  gum- elastic,  catheter  of  ordinary  length,  and  open  at 
each  end,  until  it  traversed  the  stricture  and  reached  the  bladder;  the 
catgut  bougie  was  then  withdrawn,  and  the  gum-elastic  catheter 
secured.  A  little  constitutional  disturbance  followed,  but  soon  subsided, 
and  in  a  few  days  gum-elastic  catheters  of  a  much  increased  size  were 
introduced  with  facility. 

"  A  very  remarJcahle  amendment  tooJc  place  in  his  hack  and  lower 
extremities y  in  a  very  few  days  after  the  first  introduction  of  the  instru- 
ment ;  in  fact,  it  was  almost  sudden.  Warm  baths,  friction  to  his 
limbs,  &c.,  completed  his  cure.  He  was  discharged  on  the  25th  of 
February,  at  which  time  the  power  of  his  lower  limbs  was  perfectly 
restored,  and  the  symptoms  affecting  the  urinary  system  had  dis- 
appeared." 

You  at  once  perceive  the  extreme  importance  of  this  case ;  it  bears 
directly  on  the  question  I  was  speaking  of,  and  proves  that  urethral 
irritation  may,  as  well  as  inflammation  of  the  kidneys,  give  rise  to  para- 
plegia ;  and  it  affords  another  striking  illustration  of  the  general  propo- 
sition which  I  have  laid  down. 

In  the  next  class  of  cases  we  have  to  consider,  the  cause  of  the  para- 
plegia is  extremely  obscure — I  mean  those  cases  in  which  the  paraplegia 
occurs  during  the  course  of  fever.  Here  the  other  sufferings  of  the 
patient,  and  his  general  debility,  attract  our  notice  so  exclusively,  that 


556  CLINICAL   MEDICINE. 

the  paralysis  entirely  escapes  notice  until  convalescence  is  established — 
until,  in  fact,  the  patient  wishes  to  support  himself  on  his  legs.  He 
then  finds,  much  to  his  surprise,  that  his  limbs  collapse  under  him,  and 
that  he  has  little  or  no  power  over  them ;  this  appears  to  him  the  more 
extraordinary  on  account  of  his  having  recovered  a  good  deal  of  strength 
in  his  upper  extremities.  Thus,  a  Miss  E.  was  attacked  with  fever 
while  on  a  visit  to  a  friend  in  Dublin.  She  was  attended  by  Mr.  Car- 
michael.  Her  fever  was  protracted  and  severe,  and  exhibited,  during 
its  progress,  well  marked  symptoms  of  gastro-intestinal  irritation  and 
congestion,  viz.,  tympanitis,  epigastric  and  abdominal  tenderness,  &c. 
When  her  convalescence  was  established,  her  attendants  found,  to  their 
great  alarm,  that  she  had  no  power  in  her  legs.  She  complained  of 
coldness  and  numbness  in  the  lower  extremities.  This  lady  gradually 
recovered  the  use  of  her  legs,  but  not  until  moxee  without  number,  had 
been  applied  along  the  course  of  the  spinal  column.  The  cure  lasted 
about  a  year.  No  evidence  could  at  any  time  be  detected,  indicating 
disease  of  the  spinal  bones  or  ligaments.  Mr.  Carmichael  has  seen 
several  cases  of  paraplegia  following  the  remittent  gastric  fever  of 
children,  totally  unconnected  with  spinal  disease.  Such  an  occurrence 
is  most  usual  in  children  of  a  scrofulous  temperament,  and  it  is  seldom, 
very  seldom,  remedied  either  by  time  or  medicine. 

Two  explanations  suggest  themselves  as  capable  of  accounting  for  the 
paraplegia  after  fever.  The  first  rests  upon  the  frequency  of  the  occur- 
rence of  violent  pain  in  the  small  of  the  back  in  the  commencement  of 
this  disease.  This  pain  in  the  back  is  often  excruciating,  and  generally 
accompanied  by  proportionally  violent  pains  in  the  lower  extremities. 
I  am  quite  as  anxious  to  relieve  the  pain  in  the  back  in  the  beginning 
of  fever,  as  I  am  to  remove  headache ;  one  is  almost  as  serious  as  the 
other,  for  the  vital  importance  of  the  spinal  marrow  in  the  economy  is 
scarcely  less  than  that  of  the  brain. 

In  reference  to  this  point  of  practice,  I  have  been  in  the  habit  of  using 
the  expression — ^in  order  to  fix  the  attention  of  my  pupils — that  such  a 
patient  has  not  any  pain  in  his  head,  hut  he  has  gotten  his  headache  in 
the  small  of  his  hack.  Now,  when  headache  is  the  prominent  feature 
of  the  first  stage  of  fever,  how  few  will  omit  bleeding,  leeching,  cupping, 
cold  or  hot  applications,  &c.  &c.  When,  on  the  contrary,  the  lumbar 
spinal  marrow  is  the  seat  of  the  congestion,  how  generally  do  practi- 
tioners neglect  the  application  of  topical  bleeding,  and  other  appropriate 
remedies.  Were  such  neglect  of  less  frequent  occurrence,  it  is  probable 
that  paraplegia  after  fever  would  not  be  met  with  so  often.  Some  may 
be  inchned  to  look  for  the  source  of  the  paraplegia  which  follows  fever 
in  the  irritation  of  the  gastro-intestinal  mucous  surface,  propagated  by  a 


PARAPLEGIA.  557 

reflex  progress  to  the  spinal  marrow.  It  is  not  easy  to  decide  between 
these  two  explanations,  but  I  confess  myself  more  inclined  to  adopt  the 
former  tlian  the  latter. 

I  shall  now  proceed  to  lay  before  you  some  facts  and  cases  illustrating 
the  nature  of  another  form  of  paraplegia,  a  form  of  extreme  interest, 
from  the  circumstance  of  its  being  hitherto  but  little  understood,  and 
not  mentioned  by  any  writer  I  am  acquainted  with,  as  well  as  from  the 
peculiar  nature  of  its  origin,  and  the  frequency  of  its  occurrence.  I 
have,  within  a  comparatively  short  period  of  time,  met  with  several 
instances  of  this  affection,  and  have  some  cases  of  it  at  present  under 
treatment. 

Before  I  enter  on  this  part  of  the  subject,  I  may  be  allowed  to  re- 
mark that,  in  some  cases,  loss  of  the  power  of  motion  in  a  limb  can 
evidently  be  traced  to  the  operation  of  a  cause  whose  action  is  confined 
altogether  to  the  surface.  Thus,  in  the  case  of  a  woman  in  Sir  Patrick 
Dun's  Hospital,  erysipelas  occupied  the  calf  and  inside  of  the  right  leg, 
and  occasioned  some  inflammation  and  tenderness  along  the  chain  of 
lymphatics  extending  to  the  groin,  where  one  of  the  inguinal  glands 
was  slightly  enlarged  and  painful.  The  erysipelas  yielded  to  the  em- 
ployment of  local  and  general  remedies ;  but,  for  several  days,  and  par- 
ticularly while  the  disease  was  at  its  acme,  she  was  altogether  destitute 
of  any  power  of  motion  in  the  affected  Hmb ;  she  could  neither  bend 
the  leg  on  the  thigh,  nor  could  she  raise  the  whole  limb.  This  affection 
mnst  have  been  produced  by  a  reflex  action  propagated  from  the  cuta- 
neous branches  to  the  larger  muscular  nerves.  It  is  evident,  that  the 
muscles  which  move  the  leg  on  the  thigh  could  have  been  affected  only 
in  this  way,  for  they  lay  far  above  the  part  in  which  the  erysipelatous 
inflammation  existed.  It  is  in  the  same  way  that  we  are  to  account  for 
the  paralysis  observed  in  cases  of  phlegmasia  dolens. 

Sometimes  the  reverse  of  this  happens,  and  a  single  limb  becomes 
paralysed,  on  account  of  an  injury  done  to  one  of  its  principal  nerves  by 
the  application  of  sudden  violence,  or  of  pressure  long  continued.  Thus, 
a  case  was  related  to  the  late  Dr.  Brennan  and  myself,  in  which  a  robust 
gentleman  having  been  much  fatigued  during  the  day,  fell  asleep  after 
dinner,  his  head  resting  on  his  arras  which  were  crossed  on  the  table. 
In  consequence  of  some  unfortunate  awkwardness  in  his  position,  one 
of  the  ulnar  nerves  was  compressed  during  the  time  he  slept,  and  on 
awakening,  his  fore-arm  and  hand  were  completely  powxrless.  Many 
remedies  were  tried  in  this  case  without  success,  and  the  paralysis  con- 
tinued until  the  day  of  his  death,  which  occurred  several  years  after- 
wards. A  lady  not  long  since,  was  tripped  up  in  walking  across  the 
floor,  and  fell  with  considerable  force.     The  parts  which  sustained  the 


558  CLINICAL  MEDICINE. 

principal  shock  were  the  left  hip  and  trochanter.  From  the  moment  of 
the  accident,  she  lost  all  power  in  the  left  lower  extremity,  which  re- 
mained permanently  paralytic.  Eracture  or  dislocation  was  suspected 
at  first,  but  a  minute  and  careful  examination  showed  that  the  suspicion 
was  groundless.  No  injury  of  the  spine  could  be  detected,  and  she  had 
no  numbness,  pain  or  formication  in  the  affected  limb.  After  a  month 
she  was  placed  under  the  care  of  Mr.  Kirby,  who  used  every  topical  ap- 
plication likely  to  prove  useful,  but  without  the  slightest  benefit.  She 
returned  to  the  country,  where  she  died  shortly  afterwards,  quite  unex- 
pectedly, in  the  bloom  of  hfe,  and  without  the  occurrence  of  a  single 
symptom  indicative  of  approaching  danger.     No  autopsy  was  permitted. 

I  shall  now,  with  the  view  of  illustrating  the  form  of  paraplegia  to 
which  I  have  alluded,  read  the  following  very  remarkable  case,  which  I 
had  an  opportunity  of  tracing  through  aU  its  stages,  and  which  made 
a  very  considerable  impression  on  me  at  the  time.  The  history  is  chiefly 
derived  from  notes  furnished  by  the  patient  himself  before  he  became 
too  weak  to  write ;  what  relates  to  the  latter  stages  of  his  complaint  is 
taken  from  my  own  case-book. 

Mr.  B.,  aged  twenty-three,  was  remarkably  strong  and  healthy, 
though  of  a  spare  habit.  He  was  able  to  take  a  gread  deal  of  exercise, 
capable  of  enduring  much  fatigue,  and  passionately  fond  of  hunting, 
fishing,  and  shooting,  particularly  the  latter;  and,  in  pursuit  of  his 
favourite  amusements,  frequently  exposed  himself  to  wet  feet  during 
his  excursions  through  bog  lands,  and  when  wading  in  the  water. 
These  habits,  however,  he  laid  aside  after  the  occurrence  of  the  first 
attack  of  his  iUness,  which  happened  in  1829.  He  had  for  many  years 
been  of  a  costive  habit,  his  bowels  being  frequently  confined  for  a  week 
at  a  time,  but  did  not  experience  any  sensible  bad  effects  from  this  cir- 
cumstance, and  never  took  any  aperient  medicine. 

Since  the  first  attack  in  January,  1829,  this  state  ceased,  and  his 
bowels  became  ever  afterwards  inclined  to  looseness,  which  always  in- 
creased before  the  appearance  of  one  of  the  attacks,  accompanied  by 
griping,  nausea,  and  inclination  to  vomit.  Each  attack  was  generally 
preceded  by  a  copious  secretion  of  insipid  watery  fluid  in  the  mouth, 
and  then  the  characteristic  symptoms  of  his  disease  commenced.  These 
consisted  in  obstinate  and  protracted  nausea  and  vomiting ;  he  first 
threw  up  whatever  happened  to  be  on  his  stomach  at  the  time,  and 
afterwards  everything  he  swallowed,  whether  solid  or  liquid.  The 
matter  ejected  was  at  first  acid  and  afterwards  bitter,  varying  in  colour 
from  mucous  to  bilious,  but  being  generally  of  a  greenish  and  occa- 
sionally of  a  blueish  tinge.  The  greenish  fluid  annoyed  him  much, 
from  its  extreme  bitterness,  and  the  quantity  thrown  up  in  the  course 


PARAPLEGIA.  55t) 

of  a  day  varied  from  three  to  four  quarts  of  fluid.  He  complained 
also  of  pain,  referred  to  the  stomach  or  lower  part  of  the  chest,  which 
continued  throughout  the  attack,  being  most  acute  at  its  commencement ; 
for  the  last  year,  this  sensation  had  passed  into  a  feeling  of  painful 
constriction,  which  he  described  as  a  "  contracted  feeling  of  his  inside," 
and  compared  it  to  something  like  the  effects  of  a  cord  drawn  tightly, 
so  as  to  compress  or  strangulate  his  body  exactly  along  the  outline  oc- 
cupied by  the  insertions  of  the  diaphragm.  During  the  prevalence  of 
the  attack,  he  had  profuse  perspirations,  particularly  towards  the  ter- 
mination of  each  paroxysm. 

The  dur^ion  of  the  first  attack  did  not  exceed  four  or  five  days,  after 
which  he  became  quite  well,  and  continued  so  for  six  or  seven  months, 
when  his  symptoms  suddenly  returned.  He  began  to  reject  everything 
from  his  stomach  as  before ;  but  in  the  course  of  a  few  days  the  vomit- 
ing disappeared,  and  for  a  considerable  interval  he  had  no  return  of  his 
complaint.  In  the  year  1830,  he  had  three  attacks  of  a  similar  descrip- 
tion ;  from  these  he  recovered  also  completely,  and  without  remarking 
any  diminution  of  power  in  his  lower  extremities.  In  1881,  however, 
the  disease  began  to  assume  a  more  serious  aspect ;  the  paroxysms  be- 
came much  increased  in  severity,  lasted  longer,  and  recurred  at  shorter 
intervals.  Tor  one  of  these  attacks  he  took  mercury,  and  was  saHvated. 
In  1832,  his  symptoms  became  still  more  violent,  and  the  duration  of 
the  paroxysms  more  protracted.  He  had  one  in  March,  a  second  in 
May,  and  a  third  in  June,  each  of  which  was  accompanied  by  some 
numbness  and  loss  of  power  in  the  lower  extremities ;  this,  however, 
was  slight,  and  disappeared  altogether  as  the  vomiting  subsided.  About 
this  time  he  noticed  that  his  urine  was  scanty,  and  deposited  more 
sediment  than  usual.  He  also  complained  of  being  very  apt  to  catch 
cold  whenever  he  got  out  of  bed,  and  stated  that  he  suffered  occasion- 
ally from  severe  twitches  and  pains  in  his  legs,  thighs,  arms,  and  other 
parts  of  his  body,  which  were  generally  succeeded,  and  carried  off,  by 
profuse  perspirations. 

In  August,  1832,  he  had  a  violent  attack,  which  lasted  nearly  a 
month.  The  vomiting  was  incessant,  continuing  night  and  day,  and 
he  suffered  severely  from  the  feeling  of  painful  constriction  already  de- 
scribed. On  getting  up  after  this  attack,  his  legs  suddenly  failed  him, 
and  he  dropped  down  on  the  floor  quite  powerless.  The  paralysis  did 
not  now  disappear  during  the  intervals,  although  it  grew  somewhat 
better  after  each  fit  of  vomiting  had  ceased ;  indeed  he  used  to  improve 
in  his  walking  after  the  paroxysm  had  entirely  disappeared ;  and,  aided 
by  two  sticks,  supported  himself  so  as  to  give  some  hopes  of  a  recovery 
until  a  recurrence  of  his  attack  reduced  him  again  to  a  state  of  almost 


560  CLINICAL  MEDICINE. 

total  paraplegia.  His  legs  now  began  to  waste  sensibly,  and  he  noticed 
that  they  had  lost  their  feeling  and  were  remarkably  cold.  He  also 
complained  of  severe  twitches  of  pain  in  various  parts  of  his  body,  ac- 
companied by  profuse  night  sweats,  and  turbid,  scanty  urine. 

For  some  months  before  his  death  he  was  completely  paraplegic,  and 
continued  to  be  attacked  with  violent  fits  of  vomiting.  The  vomiting 
went  on  night  and  day,  and  he  was  unable  to  retain  the  mildest  and 
most  soothing  substances  for  a  moment  on  his  stomach.  Sir  Philip 
Crampton  and  Dr.  Ireland  attended  him  with  me,  and  we  had  recourse 
to  every  thing  we  could  think  of  to  allay  the  irritability  of  his  stomach, 
but  in  vain.  After  continuing  to  resist  obstinately  every  form  of  treat- 
ment for  five  or  six  days  and  nights,  the  vomiting  would  suddenly  cease, 
the  gentleman  would  exclaim,  "  Now  I  am  well,''  and  he  could  then  eat 
with  perfect  impunity,  substances  which  would  prove  irritating  and 
indigestible  to  many  stomachs.  This  was  one  of  the  most  singular  cir- 
cumstances I  ever  witnessed.  The  transition  from  a  state  of  deadly 
nausea  and  obstinate  retching,  to  sharp  feeling  of  hunger  used  to  occur 
quite  suddenly.  One  hour  he  was  the  most  miserable  object  you  could 
behold,  racked  with  painful  constrictions  across  the  epigastrium,  alter- 
nately bathed  with  cold  perspiration,  and  rejecting  every  thing  from  his 
stomach,  the  next  found  him  eating  with  a  voracious  appetite  whatever 
he  could  lay  hold  of,  and  digesting  every  thing  with  apparent  facility. 

It  may  be  observed  that  as  the  disease  in  this  case  proceeded,  the  in- 
tervals between  the  attacks  diminished,  while  the  paroxysms  increased  in 
duration.  Tor  the  last  two  years  they  continued  only  for  four  or  five 
days,  and  appeared  at  intervals  of  six  or  seven  months  ;  latterly  they  used 
to  last  for  eight  or  ten  days,  and  returned  every  third  or  fourth  week. 
During  the  paroxysm  the  only  thing  which  he  took  was  a  little  cold 
water  with  some  brandy  and  a  few  drops  of  laudanum,  which  remained 
longer  on  his  stomach  than  any  thing  else,  and  enabled  him  to  enjoy  a 
few  minutes  sleep.  He  never  complained  of  any  headache,  and  his 
intellect  was  remarkably  clear,  and  his  memory  good. 

No  trace  of  organic  disease  could  be  detected  in  the  abdominal 
viscera,  and  there  was  not  the  slightest  tenderness  over  any  part  of  the 
spine.  He  also  retained  to  the  last  a  complete  power  over  the  bladder 
and  rectum. 

At  length  his  system  began  to  give  way ;  long  confinement  to  bed, 
and  the  frequent  recurrence  of  these  exhausting  attacks  completely  wore 
him  out,  and  he  sank  the  30th  September,  1833.  A  post  mortem  exa- 
mination was  allowed  by  his  friends,  and  we  scrutinised  every  part  of  his 
system  with  the  most  anxious  care.  The  brain,  cerebellum,  spinal  cord, 
and  their  investing  membranes,  were  carefully  inspected ;  we  examined 


PARAPLEGIA.  561 

tlie  large  nervous  trunks  that  supply  the  lower  extremities,  inspected  the 
viscera  of  the  thorax,  and  searched  for  evidences  of  disease  in  the  sto- 
mach and  intestinal  tube ;  we  could  find  none.  There  was  no  lesion  of 
the  brain  or  spinal  cord,  no  thickening  or  vascularity  of  membranes,  the 
large  nerves  exhibited  their  normal  condition,  the  stomach  was  perfectly 
healthy,  the  intestinal  canal  was  natural,  the  liver  and  other  glandular 
viscera  of  the  abdomen  without  any  trace  of  appreciable  derangement. 

Here,  then,  was  a  case  of  perfect  paraplegia  (I  say  perfect,  for  he  had 
lost  all  power  of  his  lower  extremities  for  more  than  two  months  be- 
fore his  death),  which  may  be  fairly  termed  functional,  inasmuch  as 
there  was  no  lesion  of  any  part  of  the  nervous  centres  to  explain  the 
phenomena  present.  How  then  are  we  to  account  for  them  ?  the  first 
symptoms  were  undoubtedly  those  of  abdominal  irritation,  as  manifested 
by  the  tendency  to  diarrhoea  in  an  originally  costive  habit,  accompanied 
by  violent  paroxysms  of  vomiting  which  recurred  at  distant  intervals. 
Are  we  to  attribute  this  diseased  condition  of  the  stomach  and  bowels, 
which,  from  the  remarkable  periodicity  of  its  occurrence,  was  evidently 
functional,  to  irritation,  congestion  or  inflammation  of  the  brain  or 
spinal  marrow  ?  From  the  data  we  are  in  possession  of,  it  appears  that 
this  question  must  be  answered  in  the  negative.  There  was  no  head- 
ache, heat  of  scalp,  throbbing  of  the  temporal  arteries,  or  other  sign  of 
determination  to  the  head,  of  congestion,  or  inflammation  of  the  brain 
either  before  or  during  tlie  attacks.  The  patient^s  intellect  was  all 
throughout  remarkably  clear,  and  his  memory  good. 

Again,  if  we  look  for  the  origin  of  the  disease  in  the  spinal  cord  or  its 
investments,  we  can  find  nothing  to  assist  in  explaining  the  phenomena. 
There  was  no  pain  in  any  portion  of  the  spinal  cord,  and  at  no  period  of 
his  illness  could  we  detect  any  tenderness  over  the  spinous  processes. 
The  histoiy  of  the  case  seems  to  prove  that  whatever  was  the  cause 
wliich  operated  on  the  nerves  of  the  stomach  and  intestines,  it  gradu- 
ally extended  the  sphere  of  its  morbid  influence  to  the  spinal  cord,  and, 
through  it,  implicated  the  nerves  of  the  lower  extremities.  The  case  is 
in  many  respects  highly  interesting,  and  well  worthy  of  the  attention  of 
the  pathological  inquirer.  The  dissection  was  conducted  in  the  pre- 
sence of  Dr.  Ireland  and  myself,  and  by  Mr.  Harris.  It  was  not  made 
in  a  hurried  or  careless  manner,  each  organ  was  carefully  examined,  and 
the  process  occupied  at  least  four  hours. 

The  next  case  to  which  I  shall  call  your  attention,  was  in  the  Meath 
Hospital  under  the  care  of  Dr.  Stokes. 

A  robust,  middle-aged  man  was  admitted  into  the  chronic  ward  of 
the  Meath  Hospital,  labouring  under  paraplegia.  He  stated  that  he 
was  generally  employed  as  a  boatman  about  the  river  and  port,  was  fre- 

VOL.  I.  36 


562  CLINICAL   MEDICINE. 

quentlj  exposed  to  cold  and  wet^  particularly  in  his  lower  extremities, 
and  that  he  was  in  the  habit  of  drinking  freely.  He  had  enjoyed  good 
health  until  about  seven  weeks  before  admission,  when  he  was  seized 
with  numbness  of  the  feet  and  legs,  which,  after  continuing  for  three  or 
four  days,  was  followed  by  tingling  pains  running  along  the  course  of 
the  nerves.  He  then  remarked  that  the  power  of  his  lower  extremities 
was  much  diminished,  and  this  gradually  increased  so  as  to  prevent  him 
from  walking  or  even  standing  without  support.  His  bowels  became 
obstinately  costive,  and  about  a  month  after  the  commencement  of  his 
attack,  he  perceived  that  his  urine  was  discharged  in  smaller  quantity 
than  usual,  and  that  he  was  much  more  frequently  called  on  to  pass  it 
than  before.  He  also  mentioned  that  he  had  gonorrhoea  about  six 
months  before,  and  that  he  had  used  balsam  of  copaiba  and  injections. 

Some  time  after  this  he  said  he  noticed  some  white  matter  passing 
with  the  urine,  but  did  not  pay  any  particular  attention  to  it  as  it  gave 
him  no  inconvenience.  His  appetite  was  tolerably  good,  and  he  had  no 
headache  nor  any  symptom  of  determination  of  blood  to  the  brain.  He 
denied  having  received  any  injury  of  the  back,  and  there  was  no  tender- 
ness over  the  spinous  processes  of  the  vertebrae.  He  had  no  pain  in  the 
spine,  either  before  or  since  the  occurrence  of  his  illness,  nor  was  there 
any  symptom  of  inflammation  of  the  substance  or  membranes  of  the 
spinal  cord.  When  admitted  he  had  considerable  diminution  of  sensa- 
tion and  complete  loss  of  motion  in  one  of  the  lower  extremities ;  in  the 
other  he  still  retained  some  power.  He  had  also  retention  of  urine,  re- 
quiring the  daily  use  of  the  catheter. 

The  treatment  was  as  follows  : — He  was  placed  on  one  of  Dr.  Arnott^s 
hydrostatic  beds,  as  there  was  a  great  tendency  to  stripping  over  the 
hips  and  sacrum,  a  purgative  pill  was  administered  two  or  three  times  a 
day  to  remove  the  costiveness,  and  he  was  ordered  to  be  cupped  over 
the  loins.  The  latter  was  done  in  consequence  of  his  complaining  of 
some  tenderness  on  pressure  in  the  situation  of  the  kidneys.  His  symp- 
toms, however,  went  on  without  any  improvement,  and  he  died  about  a 
month  after  his  admission. 

On  dissection  the  following  phenomena  were  observed.  The  kidneys 
— which  were  first  examined,  appeared  rather  soft,  and  of  a  yellowish 
colour,  but  there  was  no  vascularity,  suppuration,  nor  other  change  of 
structure.  The  ureters  were  somewhat  distended,  but  presented  no 
other  trace  of  disease.  The  bladder  was  contracted,  its  muscular  coat 
thickened,  and  its  mucous  membrane  very  vascular.  There  w^as  no 
affection  of  the  prostrate.  On  examining  the  spinal  cord.  Dr.  Stokes 
observed  that  he  thought  the  cauda  equina  appeared  to  be  slightly  sof- 
tened, but  remarked  that  from  its  appearance  he  could  not  state  that  it 


PARAPLEGIA.  563 

was  actually  diseased.  The  rest  of  the  spinal  cord  appeared  healthy  and 
normal ;  there  was  no  vascularity,  effusion,  nor  softening.  External  to 
the  sheath  of  the  cord  there  was  a  small,  flattened,  oval  body,  about  the 
size  of  half  a  very  small  hazelnut,  and  of  a  consistence  intermediate 
between  lymph  and  fat.  Around  this  there  was  some  slight  degree  of 
vascularity.  Dr.  Stokes  observed,  that  from  the  small  size  of  this  body, 
and  the  peculiarity  of  its  texture,  he  entertained  strong  doubts  as  to  its 
Jiaving  any  influence  in  the  production  of  the  symptoms  noticed  during 
life.  He  remarked,  although  it  might  have  been  originally  the  product 
of  inflammation,  and  have  existed  in  the  form  of  an  effusion  of  lymph, 
still  the  circumstance  of  its  conversion  into  a  fatty  substance  proved  that 
it  must  have  existed  for  a  very  considerable  time,  and  the  smallness  of 
its  size,  as  well  as  the  obscurity  of  its  origin,  did  not  by  any  means 
satisfactorily  explain  the  occurrence  of  paraplegic  symptoms. 

The  last  case,  in  connexion  with  this  subject,  which  I  have  to  lay 
before  you,  appears  to  be  analogous  in  its  mode  of  origin  to  the  former  : — 
A  gentleman  of  strong  constitution,  and  extremely  fond  of  field  sports, 
particularly  fishing  and  shooting,  exposed  himself  repeatedly  to  wet  feet 
at  a  time  when  he  was  labouring  under  the  effects  of  a  long  mercurial 
course.  Taking  large  quantities  of  blue  pill,  and  exposing  the  lower 
extremities  to  wet  at  the  same  time,  are  circumstances  which  have  an 
obvious  tendency  to  produce  disease,  and  it  is  not  to  be  wondered  if 
this  gentleman  became  the  victim  of  his  want  of  caution.  He  got 
numbness  and  weakness  in  his  legs,  which  he  at  first  attributed  to 
fatigue  and  over  exertion;  but  as  the  disease  went  on,  he  became 
more  and  more  powerless,  and,  finally,  appUed  to  me  respecting  his 
illness. 

On  examination  I  found  that  he  had  no  pain  in  the  back,  nor  tender* 
ness  on  pressure ;  nothing,  in  fact,  to  indicate  any  original  affection  of 
the  spinal  cord.  The  functions  of  the  brain  also  were  natural,  and  there 
was  nothing  about  him  to  lead  me  to  suspect  cerebral  disease.  He  had, 
however,  considerable  impairment  of  the  muscular  functions  of  the  lower 
extremities,  and  could  not  walk  without  the  aid  of  crutches,  or  some 
person  to  support  him.  In  treating  this  case,  I  looked  upon  it  as  an 
instance  of  imperfect  paraplegia,  in  wliich  the  paralysis  apparently  rose 
from  impressions  made  upon  the  sentient  extremities  of  the  nerves  of 
the  legs  and  feet,  at  a  time  when  these  nerves  were  particularly  liable  to 
be  deranged  in  their  functions  from  the  previous  use  of  mercury.  I 
therefore  had  recourse  to  remedies  directly  applied  to  the  extremities  of 
those  nerves,  and  fortunately  succeeded  in  restoring  this  gentleman  to 
the  use  of  his  limbs.  The  cure,  however,  was  not  perfect,  for  a  very 
notable  degree  of  weakness  still  remains.  . 


564  CLINICAL    MEDICINE. 

Of  this  form  of  paraplegia  I  have  now  witnessed  many  instances.  In 
most  cases  I  was  induced  to  think  that  it  arose  from  impressions  made 
by  cold  and  wet  on  the  lower  extremities.  It  is  most  commonly 
observed  in  young  gentlemen  who  are  addicted  to  fishing  and  shooting, 
and  who  in  pursuit  of  their  amusements  get  wet  feet  repeatedly,  from 
walking  over  boggy  grounds,  or  wading  in  the  water.  It  is  also  observed 
in  labourers  whose  employment  obliges  them  to  stand  in  water  for  many 
hours  together,  as  in  draining,  pump-sinking,  and  other  similar  occupa- 
tions. In  all  cases  it  assumes  the  creeping  form,  and  generally  appears 
at  first  in  one  limb,  and  afterwards  in  the  other.  There  is,  however, 
considerable  variety  in  the  rate  of  its  progress ;  in  some  cases  the  patients 
become  almost  completely  paraplegic  in  a  few  weeks  from  the  com- 
mencement of  the  disease,  in  others  it  will  go  on  for  months,  and 
even  years  before  the  power  of  the  lower  extremities  is  completely 
destroyed. 

Where  its  progress  is  slow,  it  makes  its  approach  in  an  insidious 
manner,  and  is  at  first  scarcely  noticed  by  the  patient.  Its  latency  is 
here  further  favoured  by  the  absence  of  pain,  numbness,  or  formication ; 
for  it  is  only  at  the  more  advanced  stages  of  such  cases  that  derangement 
or  diminution  of  sensation  is  noticed.  It  is  only  when  making  some 
unusual  exertioi!,  as  in  going  up  stairs  or  ascending  a  hill,  that  the 
patient  finds  a  more  than  ordinary  degree  of  weakness  in  the  lower  ex- 
tremities. The  first  symptom  which  generally  attracts  his  attention  is 
an  incapability  of  walking  as  far  as  he  has  been  accustomed,  but  this  is 
attributed  to  some  temporary  weakness,  or  is  considered  to  be  the  result 
of  previous  fatigue.  As  the  disease  progresses,  walking  up  an  ascent 
becomes  a  matter  of  some  difficulty,  there  is  a  shuffling  motion  of  the 
legs,  and  the  patient  is  apt  to  stumble  from  slight  obstructions.  Gra- 
dually the  loss  of  power  becomes  more  manifest,  it  excites  the  attention 
and  surprise  of  the  patient,  and  he  finds  that  he  is  no  longer  able  to 
walk  without  the  aid  of  a  stick  or  some  person  to  lean  on.  The  paralysis 
is,  however,  seldom  complete ;  with  the  help  of  crutches  the  patient 
continues  to  hobble  about,  and  it  is  only  in  bad  cases,  and  at  an  ad- 
vanced period  of  the  disease,  that  he  becomes  completely  paraplegic. 
The  paralysis  is  never  so  sudden  nor  so  complete  in  this  form  of  para- 
plegia, as  it  is  in  cases  of  disease  of  the  spinal  cord,  or  scrofulous  ulcer- 
ation of  the  bones  and  ligaments. 

In  other  cases,  however,  the  paraplegia,  though  evidently  of  the  same 
origin,  and  having  the  same  creeping  character,  advances  with  much 
more  rapidity ;  and  the  patient  may,  in  a  few  weeks  from  the  commence- 
ment of  the  attack,  experience  a  very  considerable  diminution  of  power 
in  the  lower  extremities.      In  such  cases  it  will  be  generally  found  that 


PARAPLEGIA.  565 

one  limb  is  much  more  affected  than  the  other,,  the  loss  of  power  being 
most  complete  in  the  limb  which  was  first  engaged. 

With  respect  to  sensation,  it  appears  to  be  aifected  as  well  as  motion. 
In  the  slow  and  chronic  form  of  this  species  of  paraplegia,  it  does  not 
attract  the  attention  of  the  patient  so  quickly  as  the  derangement  of 
muscular  power ;  it  is  generally  some  time  before  he  notices  any  dimi- 
nution of  sensation,  and  then  accidentally.  In  the  more  advanced 
stage,  however,  this  becomes  manifest,  and  is  accompanied  by  a  feeling 
of  cold  in  the  lower  limbs,  which  seldom  extends  higher  than  the  knees. 
In  the  more  rapid  and  acute  form,  the  derangement  of  sensation  is 
much  more  obvious,  and  is  generally  the  first  symptom  noticed  by  the 
patient.  There  is  at  first  a  feeling  of  numbness,  which  commences  in 
the  toes  or  feet,  and  extends  up  the  Hmb  :  this,  in  the  course  of  a  few 
days,  is  followed  by  formication  and  tingling  pains  in  the  course  of  the 
nerves,  and  then  loss  of  power  and  diminished  sensation.  Tkere  is, 
however,  in  both  these  forms  of  paraplegia^  much  less  impairment  of 
sensation  than  of  motiori,  and  the  loss  of  sensation  is  never  so  com- 
plete as  in  paraplegia  from  disease  of  the  spine. 

There  is  one  curious  symptom  occasionally  observed  in  this  disease, 
which  is,  that  before  the  appearance  of  any  decided  symptoms  of  loss 
of  power  in  the  lower  extremity,  irritation  of  the  lower  part  of  the 
digestive  tube  takes  place  :  the  rectum  becomes  morbidly  excited ;  the 
patient  complains  of  tenesmus,  and  thinks  he  is  about  to  have  an  attack 
of  piles.  This  was  the  first  symptom  observed  in  one  of  the  cases  I 
attended ;  the  patient  complained  so  much  that  we  were  induced  to  ex- 
amine the  state  of  the  rectum,  but  could  not  find  anything  to  account 
for  the  morbid  excitement.  The  same  observations  apply  to  the  bladder, 
with  this  exception,  that  the  morbid  irritability  of  this  organ  occurs 
occasionally  after  the  disease  is  confirmed  and  has  made  considerable 
progress.  On  the  whole,  however,  affections  of  the  bladder  and  rectum 
are  rare  in  this  form  of  paraplegia;  and  it  is  only  at  the  advanced 
stages  that  we  sometimes  meet  with  that  derangement  in  the  muse 
powers  of  the  bladder  and  rectum,  which  occurs  so  frequently,  and  at 
such  an  early  p'eriod,  in  the  paraplegia  from  spinal  disease. 

In  cases  of  paraplegia  from  disease  of  the  spinal  cord  or  its  invest- 
ments, it  has  been  observed  that  the  urine  becomes  altered  in  its  qua- 
lity, and  assumes  an  ammoniacal  odour.  I  have  not  observed  this  oc- 
currence in  the  forms  of  paraplegia  that  I  have  detailed.  The  urine  is 
turbid,  scanty,  and  voided  oftener  than  usual ;  but  I  cannot  say  that 
I  liave  seen  it  in  any  case  decidedly  ammoniacal,  even  in  the  advanced 
stages  of  the  disease,  and  where  the  patient  was  completely  bed-ridden. 
Should  future  observations  prove  that  this  diagnostic  mark  is  constant, 


566  CLINICAL   MEDICINE. 

it  may  be  of  some  value  in  distiiiguisliing  this  from   other  forms  of 
paraplegia. 

In  these  cases  there  is  scarcely  anything  which  would  lead  us  to  fix 
on  the  spine  as  the  seat  and  organ  of  the  disease ;  neither  can  we  j5nd 
anything  in  the  brain  with  which  we  can  connect  the  paraplegic  symp- 
toms. There  is  no  pain  of  the  head  or  of  the  spine^  very  seldom  any  tender- 
ness, the  patients  are  in  the  full  vigour  of  intellect,  and  all  the  organs 
of  sense  in  their  normal  condition.  The  functions  of  respiration  and 
circulation  are  unaffected ;  and  it  was  remarked  in  the  first  case  which 
I  have  detailed,  that  there  was  no  change  in  the  pulse,  either  during 
the  fits  of  vomiting  or  the  intervals  of  ease.  The  appetite  also  is  ge- 
nerally good ;  but,  in  almost  every  instance  I  have  met  with,  there  has 
been  remarkably  obstinate  constipation. 

With  respect  to  the  prognosis  and  treatment  of  this  form  of  para- 
plegia, I  have  but  little  to  say.  The  prognosis  is  generally  unfavourable, 
particularly  where  the  disease  has  lasted  for  some  time,  and  is  accom- 
panied by  morbid  irritation,  or  loss  of  power  in  the  bladder  or  rectum. 
It  is  also  bad,  in  proportion  to  the  slowness  with  which  it  has  come  on, 
and  the  absence  of  pain  or  formication  of  the  lower  extremities.  With 
respect  to  treatment,  I  may  observe  that  I  have  never  seen  any  benefit 
derived  from  applications  to  the  spine.  The  application  of  blisters  or 
issues  over  the  back  or  loins,  does  not  appear  to  be  productive  of  the 
least  good  efi'ect ;  of  the  latter,  I  can  speak  positively  from  experience. 
They  are  an  enduring  source  of  annoyance  to  the  patient,  and  never 
produce  the  least  amelioration  of  symptoms. 

I  am  in  the  habit  of  applying  my  local  remedies  to  the  legs  ^nd 
thighs,  selecting  those  parts  in  which  the  greatest  cutaneous  sensibility 
exists.  What  I  generally  do,  is  to  keep  up  a  succession  of  blisters 
along  the  inside  of  the  legs,  and  over  the  anterior  and  inner  parts  of 
the  thighs.  The  practice  of  medicine  furnishes  many  proofs  of  the 
utiKty  of  stimulant  applications  to  the  nervous  branches,  in  case  of 
disease  affecting  the  larger  trunks.  Thus,  in  sciatica,  a  blister  applied 
over  the  ham  or  calf  of  the  leg,  where  many  of  the  ultimate  ramifica- 
tions of  that  nerve  are  superficial,  will  frequently  produce  a  much  more 
decided  effect  than  when  applied  over  the  origin  of  the  nerve  itself. 
Liniments  of  a  stimulating  kind,  and  blisters  repeatedly  applied,  are 
the  local  means  on  which  I  chiefly  rely  in  the  treatment  of  this  form 
of  paraplegia.  After  some  time,  I  commence  with  the  use  of  strych- 
nia, and  continue  it  until  some  sensible  effect  on  the  system  is  pro- 
duced, when  I  omit  its  further  use,  and  have  recourse  to  the  exhibition 
of  sulphur.  These  are  the  two  internal  remedies  from  which  I  have 
derived  most  benefit.     I  have  in  such  cases  seen  very  good  effects  from 


PARAPLEGIA.  567 

a  perseverance  in  the  use  of  the  sulphur  electuary.  Much  also  will  be 
accomplished  by  the  external  use  of  sulphur,  in  the  form  of  baths,  and 
hence  cases  of  paraplegia  of  this  kind  might  be  materially  benefited  by 
the  internal  and  external  use  of  the  waters  of  Lucan,  Harrogate,  Baden, 
Barege,  &c.  "With  respect  to  the  use  of  mercury,  it  appears  to  be  de- 
cidedly injurious.  I  have  seen  it  given  in  three  cases ;  in  all  it  did 
much  more  harm  than  good. 


568 


LECTURE  XXXVIII. 

bell's  paralysis. STAMMERING. — VARIOUS  NEURALGIC  AFFECTIONS. 

INFANTILE    CONVULSIONS. MYELITIS. 

I  PURPOSE  to  devote  this  lecture^  gentlemen,  to  the  consideration  of 
some  other  affections  of  the  nervous  system,  of  which  I  have  not  yet 
spoken ;  and,  first,  as  to  the  prognosis  to  be  derived  from  affections  of 
the  portio  dura  of  the  seventh  pair  of  nerves. 

Sir  Charles  Bell  and  Herbert  Mayo  were  the  first  who  distinctly  enu- 
merated the  symptoms  attendant  on  paralysis  of  the  portio  dura,  and 
drew  the  attention  of  medical  men  to  the  fact,  that  this  paralysis  of 
the  face,  now  popularly  termed  "Bellas  paralysis,^'  may  often  exist 
independently  of  cerebral  disease ;  and,  consequently,  practitioners  in 
gcTieral  consider  this  affection  as  dependant  upon  some  impression  made 
upon  the  nerve  itself,  or  its  extremities,  and  unattended  with  danger. 
This  view  of  the  subject  is,  generally  speaking,  correct,  but  still  it  is 
liable  to  the  following  important  exceptions  :  I  have  seen  two  cases  of 
seizure,  evidently  apoplectic,  in  which  the  only  paralysis  that  followed 
the  seizure  was  seated  in  the  muscles  supplied  by  the  portio  dura.  This 
paralysis  yielded,  in  both  patients,  in  the  course  of  ten  days  or  a  fort- 
night, to  appropriate  general  treatment,  with  a  succession  of  small 
blisters  applied  behind  the  ear,  over  the  orbit,  and  to  the  cheek.  It 
is  difficult  to  conceive  how  any  cerebral  affection  can  give  rise  to  a  para- 
lysis limited  to  a  part  supplied  by  a  single  portion  of  the  nervous  sys- 
tem ;  but  still  such  an  occurrence  occasionally  takes  place,  not  only  in 
the  part  specified,  but  in  the  tongue  and  in  the  upper  extremity.  Nor 
is  this  isolation  of  the  paralytic  affection  in  such  cases  always  decisive 
of  a  favourable  termination ;  for  usually,  in  the  progress  of  time,  ano- 
ther apoplectic  seizure  occurs,  giving  rise  to  general  hemiplegia ;  the 
physician  must,  therefore,  deterifiine  the  degree  of  danger  attending 
BeU's  paralysis,  and  other  insulated  paralytic  affections,  not  by  the 
extent  of  the  parts  engaged,  but  by  the  cause  which  has  given  rise  to 
them. 


569 

In  almost  all  the  cases  of  BelFs  paralysis  heretofore  published,  the 
cause  has  been  local  and  external,  and  therefore  this  paralysis  is  usually 
considered  to  indicate  no  deep-seated  or  dangerous  lesion.  That  it  is 
not  always  so'  however,  the  instances  brought  forward  by  Abercrombie, 
and  Mr.  John  Hamilton,  distinctly  prove;  for,  in  both,  the  disease 
arose  from  destruction  of  the  portio  dura,  occasioned  by  caries  of  the 
petrous  portion  of  the  temporal  bone,  necessarily  fatal.  The  following 
case  is  similar,  and  is  peculiarly  instructive,  as  proving  that  caries  of 
the  petrous  portion  may  exist  in  a  very  chronic  form,  combined  with 
otorrhcea,  and  may  not  give  rise  to  any  urgent  symptoms  affecting  the 
general  health  until  long  after  the  portio  dura  has  been  destroyed,  and 
Bell's  paralysis  been  produced. 

Prom  an  attentive  consideration  of  the  history  of  the  following  case, 
it  would  appear  that  the  disease  first  destroyed  the  membrana  tympani, 
the  internal  ear,  the  ossicula,  the  portio  dura  of  the  seventh  pair  within 
the  aqueduct  of  Pallopius,  together  with  a  good  deal  of  the  petrous 
portion  of  the  temporal  bone  on  that  side  which  looks  towards  the 
tympanum.  During  this  stage,  BelFs  paralysis  was  produced  and  profuse 
otorrhcea  existed  without  any  cerebral  disturbance.  But  as  the  disease 
eat  its  way  inwards,  until  it  perforated  the  dura  mater,  the  matter 
formed  found  a  readier  exit  into  the  cavity  of  the  arachnoid,  and  an 
entirely  new  set  of  symptoms  commenced,  denoting  cerebral  and  spinal 
disturbance.  The  cessation,  or  diminution  of  the  flow  of  matter  from 
the  external  ear  at  this  point  of  time  cannot  therefore  be  considered  as 
the  result  of  a  vicarious  suppuration  set  up  in  parts  more  deeply  situated, 
but  must  be  regarded  as  the  simple  result  of  the  fact,  that  the  progress 
of  the  disease  had  formed  a  new  opening  internally,  into  which  the 
matter  found  a  readier  vent. 

A  boy  about  ten  years  old,  was  admitted  into  the  Meath  Hospital, 
labouring  under  general  dropsy.  He  appeared  of  a  scrofulous  habit, 
and  was  much  worn  down  by  long  continued  diarrhoea.  Under  appro- 
priate treatment  his  symptoms  gradually,  but  slowly  disappeared,  and 
he  was  restored  to  comparative  health.  We  now  observed  that  the 
right  side  of  the  face  was  affected  with  paralysis,  and,  on  examination, 
found  that  he  had  been  subject  to  a  discharge  from  the  right  ear  for 
seven  years  previously.  The  paralysed  cheek  presented  the  phenomena 
usually  observed  in  "  BelFs  paralysis."  He  was  attacked  soon  after 
with  acute  pain  in  the  ear,  and  in  the  left  side  of  the  head ;  a  fortnight 
after,  convulsions  set  in  ;  the  pain  moved  from  the  side  to  the  back  of 
the  head,  then  to  the  back  of  neck,  and  ultimately  extended  the  whole 
way  down  the  spine,  and  about  this  period  the  otorrhcea  diminished. 
A  few  days  before  death  he  was  attacked  with  spasms  resemiling  those 


570  CLINICAL   MEDICINE. 

of  tetanus,  and  the  surface  of  the  hody  became  exquisitely  tender  to  the 
touch.  He  never  had  any  loss  of  motion,  and  to  the  last  his  intellect 
was  perfect. 

Trom  the  period  when  the  pain  set  in  to  that  of  his  death,  the  con- 
vulsions returned  about  six  times. 

Post-Mortem, — The  portio  dura  was  dissected  on  the  face  and  found 
healthy;  the  nerve  was  also  healthy  from  its  origin  at  the  base  of  the  brain 
to  its  entrance  at  the  meatus  auditorius ;  immediately  above  this  open- 
ing the  dura  matter  was  of  a  greenish  colour,  detached  from  the  bone, 
as  if  by  fluid,  and  perforated  by  a  round  hole,  large  enough  to  admit  a 
small  crow-quill.  On  dividing  this  part  of  the  membrane,  the  space 
between  it  and  the  bone  was  occupied  by  a  thick,  greenish,  and  offen- 
sive pus,  and  the  opening  in  the  dura  mater  was  observed  to  lie  exactly 
opposite  the  foramen  in  the  petrous  portion  of  the  temporal  bone,  called 
the  aqueductus  vestihuli ;  this  opening  was  much  enlarged,  and  the 
bone  around  it  was  in  a  carious  condition.  The  nerves  at  the  base  of 
the  brain  were  bathed  in  this  thick  green  pus,  but  the  organ  itself  was 
every  where  healthy,  and  free  from  any  excess  of  vascularity.  The 
arachnoid  was  nowhere  thickened  or  opaque,  and  the  pia  mater  not  more 
injected  than  natural ;  the  ventricles  were  not  distended.  Our  attention 
was  next  directed  to  the  state  of  the  spinal  cord ;  the  theca  vertebralis 
was  much  distended  by  the  same  kind  of  matter,  which  flowed  abun- 
dantly from  any  accidental  puncture  of  the  membrane.  The  matter  was 
contained  in  the  sac  of  the  arachnoid,  which  membrane  was  quite 
healthy,  and  presented  its  usual  glistening  appearance,  no  tliickening 
or  opacity  observable  in  any  part  of  its  extent ;  the  pia  mater  was  also 
free  from  disease ;  all  the  attachments  of  the  ligamentum  dentatum  re- 
mained unbroken.  The  spinal  marrow,  on  being  slit  up,  presented  no 
trace  of  disease ;  the  roots  of  all  the  nerves  from  the  base  of  the  brain 
to  the  Cauda  equina  were  bathed  in  pus,  the  presence  of  which  fluid 
on  the  surface  of  the  brain  and  spinal  marrow,  had,  no  doubt,  irritated 
these  organs,  and  occasioned  the  tetanic  symptoms  and  the  cutaneous 
tenderness. 

Mr.  Mac  Donnell,  my  clinical  clerk,  traced  the  portio  dura  through 
the  aqueduct  of  Fallopius ;  about  a  quarter  of  an  inch  from  its  en- 
trance, the  nerve  was  completely  divided ;  the  petrous  portion  of  the 
bone  was  extensively  destroyed,  and  presented  a  mere  shell ;  the  mem- 
brana  tympani  and  all  the  internal  ear  were  destroyed. 

The  following  case  contrasts  in  an  interesting  way  with  the  former, 
exhibiting  the  vitality  of  the  parts  supplied  by  the  portio  dura,  affected 
exactly  in  an  opposite  manner,  for  the  muscles  that  in  the  one,  were 
paralyzed,  were,  in  the  other,  subject  to  a  spasmodic  action,  which 


OF   THE    POUtlO   DURA..  571 

lasted  for  several  months,  and  during  the  period  of  its  greatest  inten- 
sity returned  about  every  fourth  second.  I  am  not  aware  that  this 
disease  has  been  hitherto  described,  and  therefore  am  authorized  to 
give  it  a  name ;  and,  accordingly,  in  honour  of  the  great  man  to  whom 
we  owe  such  extensive  discoveries  on  the  physiology  and  pathology  of 
the  nervous  system,  and  who  has  more  particularly  thrown  such  light 
on  the  affections  of  the  portio  dura,  I  propose  calling  it,  "  BeWs  sjpasrm 
of  the  portio  dura" 

A  woman,  named  Quinn,  aged  40,  of  spare  habit,  was  admitted  into 
the  Meath  Hospital,  June,  1841.  She  stated  that  her  complaint  com- 
menced four  years  and  a  half  before,  in  the  following  way  : — the  lower 
eyelid  of  the  right  eye  became  affected  with  spasmodic  twitches,  pro- 
ducing a  kind  of  winking ;  and  other  muscles  of  the  face  which  receive 
branches  from  the  portio  dura,  and  which  it  is  unnecessary  to  enume- 
rate, became  affected  in  a  similar  manner  by  degrees.  This  disease  was 
unpreceded  by  pain  in  the  head,  ear,  or  any  part  of  the  face.  Her 
general  health  was  good.  On  admission,  all  the  muscles  of  the  face 
supplied  by  the  seventh  nerve,  were  affected  by  spasmodic  contractions, 
occurring  many  times  during  a  minute.  The  angle  of  the  mouth  and 
ala  nasi  of  the  right  side  were  pulled  towards  the  ear ;  the  lower  eyelid 
closed  in  a  peculiar  manner,  producing  a  rather  ludicrous  kind  of  wink- 
ing. It  was  also  observed,  that  the  platysma  myoides  participated  in 
each  spasmodic  contraction,  and  its  fibres  were  seen  throwing  them- 
selves out  strongly  in  relief,  in  well  marked  bundles.  She  also  com- 
plained that  the  os  hyoides  was  sometimes  pulled  towards  the  right  ear. 
These  phenomena  occurred  also  during  sleep y  and  were  greatly  exaggerated 
by  any  kind  of  excitement.  She  complained  of  constant  noise  in  the  right 
ear,  without  any  pain ;  but  the  sense  of  hearing  was  quite  unimpaired. 
No  diminution  of  sensation,  or  alteration  of  the  temperature  of  the 
affected  side.     Her  general  health  was  good. 

The  phenomena  presented  in  this  case  were  all  owing  to  some  un- 
known affection  of  the  portio  dura.  The  only  muscles  engaged  were 
those  receiving  branches  from  that  nerve.  We  know  that  on  quitting 
the  stylo-mastoid  foramen  the  portio  dura  sends  a  branch  to  the  stylo- 
hyoid muscle  and  another  to  the  digastric,  both  which  muscles  being 
connected  with  the  os  hyoides,  will,  of  course,  when  affected  by  spasms, 
drag  that  bone  towards  the  ear  of  the  same  side.  In  the  substance  of 
the  parotid  gland  the  nerve  divides  into  two  large  branches ;  one  as- 
cends on  the  face,  called  the  temporo-facial ;  the  other,  the  cervico- 
facial, assists  the  former  in  supplying  the  muscles  of  the  face  and  chin, 
and  also  sends  some  remarhahly  long  hrauches  to  the  platys^na  myoides 
rnmcle  and  the  other  superficial  muscles  of  the  neck.     Can  we  explain 


572  CLINICAL   MEDICINE. 

the  constant  noise  in  the  ear^  unaccompanied  hy  pain  or  loss  of  hearing, 
bj  a  similar  spasmodic  action  of  those  small  muscles  of  the  internal  ear 
which  receive  branches  from  the  portio  dura,  by  which  a  muscular  bruit 
was  produced,  the  intensity  of  which  may  have  been  greatly  exaggerated 
by  its  vicinity  to  the  organ  of  hearing  ? 

Let  me  next  call  your  attention  to  neuralgic  affections  of  the  larynx. 
The  first  case  which  I  shall  speak  of  occurred  in  a  young  lady  originally 
of  vigorous  constitution,  but  latterly  suffering  from  menstrual  irregu- 
larity and  hysteria.  The  laryngeal  afi'ection  had  been  considered  to  be 
inflammatory  in  the  country,  and  had  been  treated  with  purgatives, 
leeches,  blisters,  antimonials,  and  finally  mercurialization.  No  rehef 
had  been  obtained,  and  she  came  to  Dublin  where  she  was  placed  under 
my  care,  and  that  of  Sir  Henry  Marsh  and  Mr.  Barker.  The  pain  had 
become  almost  constant  when  we  first  saw  her,  but  was  by  no  means 
violent,  except  now  and  then  when  it  used  to  become  suddenly  aggra- 
vated. These  paroxysms  of  pain  could  not,  properly  speaking  be  called 
violent;  they  were,  however,  distressing,  and  amounted  to  a  most 
annoying  feeling  of  distress  about  the  whole  region  of  the  larynx. 
There  was  no  external  tenderness,  and  the  internal  fauces  were  healthy. 
We  considered  it  to  be  a  hysterical  nervous  affection.  This  neuralgia 
was  chiefly  remarkable  for  a  change  of  tone  and  weakness  in  the  voice 
which  invariably  attended  the  paroxysms,  shewing  that  the  rima  glottidis 
and  the  cJiordcB  vocales  were  the  parts  chiefly  implicated.  We  must 
suppose,  therefore,  that  the  pain  was  derived  from  the  branches  of  the 
superior  laryngeal  nerve,  which  Dr.  Eeid  has  proved  to  be  chiefly 
sensitive. 

The  alteration  of  voice  which  accompanied  the  paroxysms  of  pain 
must  be  considered  as  a  proof  that  the  superior  laryngeal  nerve  has 
some  influence  on  the  motions  of  the  vocal  organ,  unless,  indeed 
we  adopt  the  supposition  that  the  affection  extended  likewise  to  the  in- 
ferior laryngeal  nerve.  The  facts  of  the  case  contain  nothing  decisively 
confirming  or  negativing  either  hypothesis. 

We  first  gave  large  doses  of  carbonate  of  iron,  which  had  the  effect 
of  rendering  the  attacks  periodic.  Every  morning,  at  ten  o'clock  to  the 
minute,  the  paroxysm  commenced.  The  dose  of  iron  was  now  increased, 
afterwards  sulphate  of  quina,  and  finally  arsenic  was  employed,  but 
without  any  corresponding  improvement.  The  degree  of  suffering 
became,  indeed,  less  severe,  and  its  duration  less  protracted,  but  it  ap- 
peared extremely  doubtful  whether  the  improvement  was  not  owing 
more  to  time  than  to  medicine.  Under  these  circumstances  we 
thought  it  prudent  to  desist  from  all  active  treatment,  and  we  recom- 


NEURALGIC    AFFECTIONS    OP   THE    LARYNX.  578 

mended  change  of  air,  scenery,  and  the  use  of  chalybeate  mineral 
waters. 

This  case  affords  a  striking  example  of  the  curious  fact,  that  medi- 
cines administered  for  the  purpose  of  relieving  a  disease  more  or  less 
fluctuating  or  remittent  in  its  character,  will  sometimes  render  it  strictly 
periodic,  with  marked  paroxysms  and  free  intervals.  Having  produced 
so  striking  an  effect  with  our  remedies,  we  are  apt  to  calculate  with  con- 
fidence on  still  further  improvement,  and  we  increase  the  doses  of  tonics 
with  boldness  and  full  of  hope;  disappointment,  however,  here  awaits 
us,  for  no  tonic  will  be  found  capable  of  affecting  any  further  alteration 
or  shortening  of  the  fit.  In  such  cases  we  cannot  be  too  much  on  our 
guard,  lest  we  injure  the  constitution  by  too  frequent  attempts  to  pro- 
cure a  diminution  of  suffering. 

Loss  of  speech  arises  sometimes  from  lesions  of  apparently  a  very 
trifling  character.  A  person  may  totally  lose  his  speech  without  any 
previously  existing  or  premonitory  symptoms  indicative  of  nervous 
lesion — without  liaving  experienced  any  sensation  of  pain  or  vertigo, 
any  noise  in  the  ears,  any  indications  of  determination  to  the  head — in 
fact,  without  any  thing  to  show  that  the  aphonia  was  connected  with 
any  particular  state  of  the  brain.  Thus,  a  barrister,  whom  I  attended 
with  Dr.  Beatty,  was  walking  up  and  down  the  hall  of  the  Eour  Courts, 
waiting  for  a  case  to  come  on,  and  chatting  with  one  friend  and  another; 
as  the  hall  was  rather  crowded  and  hot,  he  went  out  into  the  area  of 
the  courts  for  the  sake  of  the  air,  and  had  not  remained  there  more 
than  ten  minutes  when  an  old  friend  from  the  country  came  up  and 
spoke  to  him.  He  was  pleased  to  see  his  friend,  and  wished  to  inquire 
about  his  family,  when  he  found,  to  his  great  surprise,  that  he  could 
not  utter  a  single  audible  sound ;  he  had  completely  lost  his  voice.  He 
recovered  the  use  of  his  tongue  in  about  three  weeks,  but  not  com- 
pletely for  some  slowness  of  speech  remained.  When  loss  of  speech 
was  first  perceived  his  friend  brought  him  home  in  a  carriage ;  and 
during  the  day  he  had  several  attacks  of  vertigo,  and  afterwards  hemi- 
plegia. Tor  several  hours,  however,  before  distortion  of  the  face  or 
any  of  the  usual  symptoms  of  paralysis  had  commenced,  the  only  exist- 
ing symptom  was  loss  of  speech.  This  gentleman  died  of  apoplexy  in 
about  two  months. 

In  many  cases  of  paralysis  you  will  find  that,  although  the  patients 
have  lost  the  power  of  utterance,  yet  the  motions  of  the  tongue  appear 
to  be  nowise  deranged.  In  the  majority  of  cases  it  can  be  shortened, 
elongated,  raised,  depressed,  or  moved  from  side  to  side,  with  as  much 
apparent  facility  as  in  a  state  of  health ;  and  yet  the  voice  is  in  some 
instances  very  much  impaired — in  others,  totally  lost.     In  such  cases  it 


574  CLINICAL   MEDICINE. 

would  appear  tliat  the  defect  lies  in  the  glottis,  which  forms  and  modu- 
lates the  voice,  and  not  in  the  tongue  or  lips,  which  divide  and  articu- 
late it.  Indeed,  this  is  evident  to  any  one  who  observes  the  interrupted 
and  spasmodic  efforts  which  paralytic  persons  make  when  speaking ;  they 
are,  in  fact,  all  stutterers. 

A  young  gentleman  of  delicate  constitution,  and  who  is  now  about 
sixteen  years  of  age,  continued  to  enjoy  tolerably  good  health  up  to  his 
sixth  year.  When  about  six  years  of  age  he  went  to  bed  one  night  in 
health  and  without  any  unusual  symptom,  but  on  getting  up  in  the 
morning  it  was  observed  that  he  had  lost  his  speech,  and  was  unable  to 
articulate  a  single  word.  His  family  became  alarmed,  and  sent  for  a 
physician  immediately ;  the  boy  got  some  internal  medicine  and  a  stimu- 
lant gargle,  and  recovered  his  speech  in  a  few  days,  without  the  occur- 
rence of  any  symptom  of  laryngeal  inflammation  or  cerebral  disease. 
But  what  was  remarkable  in  the  case  was  this  :  the  boy  who  up  to  this 
period  had  spoken  well  and  distinctly,  now  got  a  terrible  stutter. 

This  resisted  all  kinds  of  treatment,  and  for  ten  years  he  continued  to 
stammer  in  the  most  distressing  way,  and  was  so  annoyed  by  it  himself 
that,  when  a  boy,  he  used  to  stamp  on  the  ground  with  vexation  when- 
ever he  failed  in  uttering  what  he  wished  to  express.  In  the  month 
of  May  last  he  got  an  attack  of  chronic  laryngitis  of  a  scrofulous  cha- 
racter, and  evidently  the  precursor  of  phthisis.  Dr.  Stokes  and  I  have 
examined  him,  and  we  feel  convinced  that  tubercular  deposition  is  going 
on  in  the  lungs.  But  what  is  most  curious  in  the  case  is  this  :  after 
he  got  the  laryngitis,  a  very  peculiar  change  took  place ;  the  laryngeal 
inflammation  modified  the  tone  of  his  voice  so  as  to  make  it  a  little 
husky,  but  tke  stammering  has  completely  ceased. 

You  are  aware  that  stammering  has  been  explained  as  depending  on 
spasm  of  the  muscles  which  are  employed  in  modifying  the  column  of 
air  as  it  rushes  through  the  narrow  aperture  of  the  glottis.  At  certain 
times,  and  under  a  variety  of  circumstances,  those  fine  muscular  organs 
become  spasmodically  affected,  the  vocal  chords  no  longer  undergo  the 
same  steady  and  exact  tension  and  relaxation,  and  speech  becomes  in- 
terrupted in  consequence  of  frequently  recurring  closure  of  the  glottis. 

In  the  case  to  which  I  have  referred — inflammation  taking  place  in 
the  mucous  membrane  covering  these  delicate  muscular  fibres,  you  can 
conceive  that  either  the  thickening  of  the  mucous  membrane,  or  the 
alteration  in  the  state  of  its  vitality,  may  have  so  modified  the  disposi- 
tion of  the  parts,  that  they  become  incapable  or  indisposed  to  undergo 
those  rapid  contractions  necessary  to  produce  stammering,  by  inducing 
closure  of  the  glottis  at  the  moment  that  its  aperture  ought  to  remain 
open.     The  case  itself,  however,  is  an  extremely  curious  one,  and  I  do 


STAMMERING.  575 

not  believe  that  there  is  any  similar  one  on  record.  Every  thing  whicli 
bears  on  the  cure  of  so  important  a  disease  as  stammering,  even  though 
it  be  accidental,  and  not  the  result  of  medical  care  and  ingenuity,  is  of 
great  value,  inasmuch  as  it  tends  to  place  the  causes  of  the  disease  in  a 
clearer  light.  In  this  point  of  view  I  look  upon  the  case  as  one  of 
very  great  interest. 

There  is  one  curious  fact  with  reference  to  stammering  which  I  do  not 
think,  has  been  before  noticed,  namely,  that  women  very  rarely  stam- 
mer. In  a  family  of  my  acquaintance,  this  defect  of  the  speech  has 
been  hereditary  among  the  males  for  three  generations,  but  the  females 
have  in  no  single  instance  been  so  affected. 

With  respect  to  the  cure  of  stammering,  I  have  recently  discovered 
a  method  by  which  the  most  inveterate  stutterer  may  be  enabled  to 
obtain  utterance  for  his  words  with  tolerable  fluency.  It  is  simply  by 
compelling  him  to  direct  his  attention  to  some  object,  so  as  to  remove 
it  from  the  effort  he  makes  to  speak.  Thus  I  direct  him  to  hold  a  rule 
or  bit  of  stick  in  his  right  hand,  and  with  it  to  strike  the  forefinger  of 
the  left  in  regular  time,  with  the  words  he  is  uttering ;  the  eye  must  be 
fixed,  and  all  the  attention  directed  to  the  finger  he  is  striking,  and  the 
time  must  be  strictly  kept  with  the  syllables.  This  method  I  have  tried 
in  several  instances  with  complete  success,  and  Dr.  Nehgan  informs  me 
that  since  I  first  mentioned  it  to  him,  he  has  found  it  completely  effec- 
tual in  numerous  cases.  Although,  of  course  when  thus  employed, 
this  plan  can  only  be  regarded  as  a  means  of  affording  temporary  relief ; 
I  have  no  doubt  that  if  it  were  perseveringly  followed  out  with  young 
persons  who  stammer,  both  in  reading  and  speaking,  it  would  cure  them 
permanently  of  this  unpleasant  affliction.  Its  efficacy  would  seem  to 
prove,  that  stammering  is  altogether  a  nervous  affection. 

With  reference  to  neuralgia,  we  find  that  it  attacks  various  parts  of 
the  body,  and  amongst  others  the  mammae. — An  unmarried  lady  resid- 
ing in  the  neighbourhood  of  Dublin,  consulted  me  in  July,  1829,  for 
this  affection.  She  was  of  the  sanguineous  habit,  robust,  and  other- 
wise healthy.  The  disease  had  lasted  two  years  with  various  degrees  of 
violence ;  the  breasts  being  at  times  nearly  free  from  pain,  but  gene- 
rally they  were  very  troublesome.  During  the  paroxysms,  which  often 
lasted  several  days,  and  sometimes  considerably  longer,  the  mammae, 
which  in  this  lady  were  full  and  large,  became  extremely  painful  and 
tender,  but  were  neither  tumefied,  hard,  nor  red.  The  intervals  between 
the  paroxysms  were  marked  not  only  by  a  total  cessation,  but  by  a 
gradual  diminution  of  pain.  At  no  period  had  there  been  any  spinal 
tenderness.     One  breast  was  not  more  affected  than  the  other,  and  the 


576  CLINICAL   MEDICINE. 

axillary  glands  were  not  swollen.  She  had  consulted  several  practi- 
tioners, had  taken  much  medicine,  and  made  use  of  many  topical  appli- 
cations, without  relief.  Leeches  had  been  repeatedly  applied,  but  their 
bites  had  invariably  caused  excruciating  pain,  and  the  bleeding  they 
occasioned  was  not  followed  by  the  least  relief. 

I  at  first  tried  stupes,  narcotic  liniments,  and  plasters,  with  warm 
salt-water  baths,  but  these  measures  were  unattended  with  the  least 
improvement.  The  absence  of  complete  intermissions,  and  of  well 
marked  paroxysms,  prevented  me,  during  several  weeks,  from  perceiving 
the  true  neuralgic  nature  of  this  pain  ;  at  last  this  view  of  the  subject 
occurred  to  me.  I  tried  the  carbonate  of  iron,  with  marked  benefit. 
The  disease  has  since  frequently  recurred,  but  its  violence  has  always 
been  lessened  by  the  carbonate  of  iron.  Sea  bathing  she  likewise  finds 
useful.  I  may  here  observe,  that  in  those  cases  of  neuralgia,  in  which 
carbonate  of  iron  proves  useful,  I  never  found  it  necessary  to  raise  the 
dose  beyond  one  drachm,  three  times  a  day.  Indeed  a  larger  dose  than 
half  a  drachm  is  seldom  required.  This  statement  of  my  experience  I 
consider  necessary,  to  counteract  the  impression  made  on  the  minds  of 
students  by  a  perusal  of  some  of  the  London  periodicals,  w^here 
enormous  doses  of  carbonate  of  iron  are  recommended  by  Dr.  Elliotson. 

I  have  examined  tliis  subject  in  a  practical  point  of  view  with  great 
attention,  and  think,  that  what  is  true  concerning  carbonate  of  iron, 
applies  also  to  most  tonic  medicines.  In  fact  we  may  consider  it  as  a 
general  rule,  that  tonics  are  rarely  indicated,  where  moderate  doses  do 
not  effect  the  desired  purpose.  This  applies  more  particularly  to  the 
stronger  tonics,  such  as  the  salts  of  iron,  of  arsenic,  and  quina.  I  can 
scarcely  conceive  a  case  possible,  in  which  a  judicious  physician  will  find 
it  necessary,  for  instance,  to  give  more  than  ten  grains  of  sulphate  of 
quina  in  a  day,  and  yet  much  larger  doses  are  not  unusual  here  and 
elsewhere.  Whenever  the  symptoms  supposed  to  call  for  such  a  treat- 
ment, resist  moderate  doses  of  sulphate  of  quina,  we  ought  to  pause, 
and  reflect  whether  another  plan  of  treatment  ought  not  to  be  adopted. 

There  are  two  states  of  the  system  attended  frequently  with  well 
marked  rigors,  febrile  paroxysms,  and  intermissions  closely  resembling 
ague ;  I  mean  internal  suppuration,  and  local  inflammation  without 
suppuration.  Practical  physicians  are  fully  aware  of  this  circumstance, 
hut  there  is  another  condition  of  the  system  in  vjhich  si/mptoms  simula- 
ting ague  arise,  totally  unconnected  with  inflammation,  and  of  which  I 
have  seen  two  remarkable  examples.  They  both  occurred  in  females.  One, 
a  lady  of  a  nervous  temperament,  in  about  a  fortnight  after  her  confine- 
ment was  affected  with  well  marked  symptoms  of  quotidian  ague,  which 
grew  worse  and  more  violent  during  the  exihibition  of  very  large  doses 


NEUUALGIA   OF   THE    TESTICLE.  577 

of  sulphate  of  quina;,  but  she  rapidly  got  rid  of  her  complaint  when,  at 
my  suggestion,  camphor,  aromatic  spirit  of  ammonia,  &c.,  were  substi- 
tuted in  its  place.  In  anotlier  lady,  symptoms  of  tertian,  and  after- 
wards of  double  tertian,  had  continued  for  many  weeks,  and  had  re- 
duced the  patient  extremely,  sulphate  of  quina,  arsenic,  and  opium 
had  successively  received  a  fair  trial,  but  in  vain.  The  disease,  how- 
ever, finally  yielded  to  the  exhibition  of  diffusible  stimulants,  used  in 
combination  with  antacids, 

I  cannot  point  out  how  such  cases  are  to  be  distinguished  from  ague, 
except  it  be  by  the  failure  of  the  sulphate  of  quina.  Prom  local  inflam- 
mations and  suppuration  they  may  in  general  be  distinguished  with  faci- 
Hty.  I  may  here  observe,  that  in  a  gentleman  treated  by  Sir  Henry 
Marsh  and  myself,  violent  symptoms  of  ague  depended  on  the  presence 
of  a  number  of  very  small  abscesses  in  the  liver.  Here  sulphate  of 
quina  given  in  lavements,  caused  a  cessation  of  the  rigors,  hut  did  not 
diminish  the  other  symptoms  of  fever  ;  on  the  contrary,  had  it  been  per- 
severed in,  the  intermittent  would  have  been  evidently  converted  into 
a  continued  fever. 

The  influence  of  sulphate  of  quina  in  preventing  rigors,  even  where 
it  cannot  remove  the  cause  of  constitutional  irritation,  is  well  illustrated 
by  its  effects  where  the  symptoms  depend  on  stricture  of  the  urethra ; 
and  ought  to  be  recollected  by  every  practitioner,  lest  he  be  misled  oc- 
casionally by  this  partial  improvement  into  an  injudicious  continuance 
of  the  medicine.  Where  sulphate  of  quina  is  intended  to  act  as  a  tonic, 
I  am  persuaded  that  the  dose  should  never  exceed  a  grain  three  times  a 
day,  and  generally  even  smaller  quantities  are  sufficient ;  when  a  com- 
bination of  tonic  and  purgative  medicines  is  required,  all  our  intentions 
may  be  answered  by  a  combination  of  sulphate  of  quina  in  proper  quantity, 
with  the  compound  extract  of  colocynth,  or  the  aloetic  piU  with  myrrh. 

Neuralgia  of  the  testicle  is  not  a  very  common  form  of  disease,  but 
it  requires  notice,  as  it  gives  rise  to  excruciating  agony,  and  constitutes 
one  of  the  most  painful  affections  that  can  be  imagined.  I  have  seen 
two  examples  of  it  within  the  last  year ;  the  first  was  a  young  gentle- 
man of  highly  irritable  nerves,  who  had  studied  hard  and  dissipated 
much ;  in  him  the  paroxysms  of  pain  did  not  observe  any  very  marked 
period,  but  returned  daily  at  uncertain  intervals,  which  grew  shorter 
and  shorter,  until  at  last,  he  had  scarcely  any  respite  day  or  tight. 
There  was  no  fever,  and  not  the  shghtest  appearance  of  local  congestion 
or  inflammation.  When  attacked  with  a  paroxysm  the  patient  would 
throw  himself  on  the  floor,  and  roll  about  in  the  greatest  agony,  cov- 
ered with  a  cold  perspiration.  This  case  yielded  to  large  doses  of  car- 
VOL.  I.  '  '37 


578.  CLINICAL  MEDICINE. 

bonate  of  iron  freshly  prepared,  and  frequent  inunction  of  the  testicle 
and  cord  with  belladonna  ointment.  The  second  case  of  neuralgia  of 
the  testicle  occurred  in  a  gentleman  who  laboured  under  neuralgic  pains, 
decidedly  of  a  gouty  nature.  In  him  the  pain  of  the  cord  and  testicles 
used  to  come  on  every  afternoon  about  four  o'clock,  and  continue  for 
several  hours.  The  pain,  though  considerable,  did  not  approach  the 
degree  of  agony  experienced  in  the  first  case.  It  was  at  times,  how- 
ever, so  severe  as  to  compel  him  to  groan  aloud.  This  neuralgia  of 
the  testicle  -disappeared  after  a  few  days,  and  was  replaced  by  a 
violent  gouty  pain  in  the  loins  and  right  hypochondrium.  The  latter 
yielded  to  the  usual  local  treatment  and  the  use  of  colchicum 
internally. 

A  man  was  admitted  into  the  chronic  ward  a  few  days  ago  who  can- 
not separate  the  lower  from  the  upper  jaw  to  the  distance  of  more  than 
two  lines.  What  are  the  cases  in  which  we  find  this  immobility  of  the 
lower  jaw  ?  Most  commonly  in  tetanus  or  locked-jaw ;  but  here  this 
cannot  be  the  case,  for  the  man  has  no  sign  indicative  of  a  tetanic  affec- 
tion, no  rigidity  of  the  muscles  of  the  neck ;  his  countenance  is  very 
different  from  that  of  a  tetanic  patient,  and  he  has  not  been  exposed  to 
any  of  the  ordinary  exciting  causes  of  that  disease.  But  leaving  all  con- 
sideration of  the  nature  of  the  disease  out  of  the  question,  what  is  it 
that  prevents  him  from  moving  his  lower  jaw  ?  It  must  depend  on  one 
of  two  causes ;  either  the  muscles  which  perform  the  motions  of  the 
lower  jaw  are  stiff,  rigid,  and  incapable  of  motion,  or  else  there  is  some 
disease  of  the  articulation  which  obstructs  the  motion  of  the  bone. 
This  proposition  is  universally  true  of  all  articulations,  that  when  they 
become  impeded  or  completely  obstructed  in  their  motions,  the  derange- 
ment arises  from  some  abnormal  condition  of  the  muscles,  or  of  the 
bones  and  ligaments  which  form  the  joint. 

In  this  case  we  find,  that,  in  addition  to  being  unable  to  perform  the 
proper  motions  of  the  lower  jaw,  the  patient  has  intense  pain,  darting 
from  the  angle  of  the  jaw  towards  the  temple,  the  ear,  and  the  side  of 
the  neck.  This  pain  is  of  an  extremely  violent  character,  so  as  to  re- 
semble tic  douloureux,  and  the  resemblance  is  still  farther  increased  by 
its  being  more  or  less  intermittent.  Now,  on  inquiry  into  the  history 
of  this  case,  we  find  that  the  patient  had  some  time  ago  laboured  under 
toothache,  for  which  he  had  the  last  molar  tooth  but  one  of  the  upper 
jaw  extracted,  and  that  immediately  afterwards  he  was  seized  with  vio- 
lent pain  in  the  part,  and  found  that  he  could  no  longer  move  his  lower 
jaw  as  usual.  I  have  seen  many  cases  of  this  kind,  in  which  a  painful 
or  carious  tooth,  or  an  injury  done  to  the  gum  or  jaw,  has  been  followed 


CASES    SIMULATING   TIC   DOULOUREUX.  579 

by  violent  darting  pain  in  the  nerves  of  the  face,  simulating  in  many 
particulars  tic  douloureux. 

I  remember  being  sent  for  to  Middleton,  near  Cork,  some  time  since, 
to  see  a  young  lady  of  delicate  constitution,  whose  health  was  materially 
deranged  from  what  was  said  to  be  an  attack  of  tic  douloureux.  She  had 
been  under  the  care  of  many  practitioners,  and  had  used  very  large 
doses  of  the  carbonate  of  iron  and  sulphate  of  quina,  and  at  the  time 
I  visited  her  was  taking  arsenic.  The  first  thing  I  did  on  my  arrival 
was  to  examine  her  teeth.  On  close  inspection  I  observed  that  on  the 
crown  of  one  of  the  upper  molar  teeth  there  was  a  spot  wliich  appeared 
to  be  decayed,  and  found  on  inquiry  that  she  had  frequently  suffered 
from  pain  in  this  spot  when  she  drank  any  cold  liquid.  I  had  the  tooth 
drawn  and  soon  afterwards  the  pain  completely  ceased.  Yet  in  this 
case  the  pain  was  not  only  of  an  intense  character,  preventing  sleep  and 
wearing  out  her  strength,  but  it  had  its  intermissions,  and  was  aggra- 
vated at  particular  hours  of  the  day. 

Another  instance  of  the  same  kind  came  under  my  notice  about 
twelve  months  ago.  A  young  lady  was  brought  to  me  by  a  medical 
friend  of  her's  to  have  my  advice  for  an  attack  of  tic  douloureux.  She 
had  been  attended  by  this  gentleman  with  great  care,  and  no  mode  of 
rebef  left  untried,  for  her  sufferings  were  intense,  and  she  had  constant 
exacerbations  of  pain.  I  asked  him,  were  her  teeth  sound,  or  had  she 
any  disease  of  the  gum  or  jaw  ?  He  said  not,  and  that  he  was  sure 
of  this,  for  he  had  examined  her  teeth  over  and  over  again.  On  open- 
ing her  mouth,  however,  I  thought  I  saw  some  unsoundness  in  one  of 
the  teeth,  and  recommended  her  to  go  to  Mr.  M'Clean  and  get  it  drawn. 
She  did  so  and  the  pain  quickly  disappeared. 

I  could  also  give  you  many  cases  in  which  an  injury  done  to  some  of 
the  branches  of  the  dental  nerve  has  given  rise  to  symptoms  closely  re- 
sembling those  of  tic  douloureux.  One  of  the  most  curious  circum- 
stances connected  with  such  cases  is,  that  the  pain  is  always  of  a  more  or 
less  intermittent  character.  The  same  thing  is  observed  in  that  form  of 
headache  which  arises  from  irritation  of  the  brain,  produced  by  spiculse 
of  bone  growing  from  the  internal  table  of  the  skull.  In  a  case  which 
occurred  sometime  back  at  the  Meath  Hospital,  where  several  spiculae, 
some  of  them  more  than  a  quarter  of  an  inch  in  length,  were  pressing 
on  the  brain,  the  headache  was  of  a  distinctly  intermittent  character. 
This  remarkable  periodicity  of  exacerbation,  in  cases  where  the  opera- 
tion of  the  exciting  cause  continues  still  the  same,  seems  to  be  peculiar 
to  the  nervous  system. 

In  many  cases  considerable  derangement  of  the  facial  nerves  is  found 
to  follow  an  injury  done  to  some  branch  of  the  dental  nerve  in  drawing 


580  CLINICAL  MEDICINE. 

a  tootli.  When  the  bone  has  been  injured  by  the  force  used  in  extract- 
ing the  tooth,  it  frequently  happens  that,  if  the  injury  be  not  quickly 
repaired,  and  the  parts  healed  up,  symptoms  resembling  those  of  tic 
douloureux  or  rheumatic  neuralgia  will  supervene,  and  give  the  patient 
a  great  deal  of  annoyance.  Such  was  the  origin  of  the  mischief  in  the 
case  before  us ;  the  man  received  an  injury  of  the  upper  jaw  in  drawing 
a  tooth  which  is  not  as  yet  healed,  as  you  may  perceive  by  introducing 
a  probe  between  the  separated  portions  of  gum,  when  you  will  find  it 
grate  against  the  rough  surface  of  the  bone.  In  addition  to  this,  there 
are  considerable  tenderness  of  the  gum  and  swelling  of  the  neighbouring 
parts,  which  have  extended  to  the  muscles,  their  sheaths,  and  finally  to 
the  articulation  of  the  lower  jaw.  You  can  satisfy  yourselves  of  this 
by  examining  the  parts  and  striking  the  lower  jaw,  so  as  to  press  it 
suddenly  upwards  and  backwards  into  the  glenoid  cavity,  just  in  the 
same  way  as  you  press  the  thigh  bone  against  the  acetabulum  when  you 
wish  to  ascertain  whether  there  is  inflammation  of  the  hip  joint.  The 
motion  of  the  lower  jaw  is  here  prevented  by  inflammation,  extending 
from  the  upper  jaw  so  as  to  involve  its  ligaments  and  the  neighbouring 
muscular  sheaths. 

There  are  other  causes  also,  which  may  be  attended  with  the  same 
diminution  of  motion  in  the  joint.  Thus  a  man  may  get  an  attack  of 
rheumatism  in  the  scalp,  which  may  extend  to  the  temporal  muscles  and 
prevent  him  from  being  able  to  depress  his  lower  jaw,  and  I  have  known 
cases  in  which  this  condition  of  the  temporal  muscle  has  given  rise  to 
suspicions  of  the  existence  of  trismus.  When  you  examine  the  articu- 
lation you  find  nothing  amiss,  but  when  you  come  to  press  on  the  tem- 
poral muscle  above  the  zygoma,  the  patient  complains  of  pain  and  ten- 
derness. The  irritation  produced  by  rheumatic  inflammation  gives  rise 
to  a  fixed  rigid  state  of  the  muscle,  and  hence  the  patient  cannot  open 
his  mouth.  This  form  of  disease  I  have  described  long  since,  in  a  paper 
pubhshed  in  the  Dublin  Hospital  Eeports.  It  can  be  relieved  with 
great  ease  by  applying  leeches  to  the  temple,  and  ordering  the  patient 
to  rub  over  the  part  a  small  portion  of  mercurial  ointment  with  extract 
of  belladonna  two  or  three  times  a  day.  The  same  state  of  the  temporal 
muscle  is  sometimes  observed  as  resulting  from  an  extension  of  inflam- 
mation, in  case  of  a  wound  of  the  scalp  in  its  vicinity. 

In  the  case  before  us,  almost  every  thing  will  depend  on  the  process 
which  nature  may  adopt  with  respect  to  the  injury  of  the  maxillary  bone. 
If  the  bone  throws  up  healthy  granulations,  and  the  inflammatory  pro- 
cess ceases,  the  affection  of  the  nerves,  as  well  as  of  the  muscles  and 
joint,  will  quickly  subside.  All  we  can  do  under  the  circumstances  is 
to  apply  leeches  over  the  side  of  the  face,  and  order  the  man  to  rub  in 


INFANTILE    CONVULSIONS.  581 

mercurial  ointment ;  every  thing,  however,  wiU  depend  on  the  turn  the 
disease  of  the  bone  may  take. 

Let  me  next  call  your  attention  shortly  to  infantile  convulsions,  more 
especially  those  which  attack  children  at  the  ages  of  two,  four,  and 
six  months,  and  to  the  utility  of  oil  of  turpentine  in  their  treatment. 

When  we  consider  the  convulsive  affections  of  the  infantile  period, 
w^e  find  that  they  may  arise  from  a  variety  of  causes.  In  the  first  place, 
they  may  be  produced  by  the  process  of  dentition.  Some  persons  seem 
to  think  this  impossible ;  but  it  is  not  only  possible,  but  true :  for 
teething  is  capable  of  exciting  a  very  great  degree  of  irritation  in  the 
system.  We  also  observe  that  an  irritable  state  of  the  brain,  accom- 
panied by  a  hydrocephalic  tendency,  will  produce  convulsions ;  but  in 
very  many  instances,  particularly  in  children  of  the  ages  mentioned 
above,  they  proceed  from  intestinal  irritation.  Of  those  forms  which 
spring  from  the  irritation  of  dentition,  or  of  cerebral  excitement,  I  do 
not  intend  to  speak,  as,  on  these  matters,  the  standard  medical  works 
furnish  abundant  information.  I  shall  restrict  myself,  therefore,  to 
some  observations  on  those  convulsions  which  depend  on  intestinal 
irritation. 

As  such  convulsions  frequently  arise  from  causes  which  affect  diges- 
tion, and  produce  a  change  in  the  mode  of  nutrition,  they  appear  very 
soon  after  birth.  The  animal  which  but  a  short  time  before  was  nou- 
rished by  the  placenta,  is  now  supported  by  ingesta ;  and  hence,  from 
tliis  sudden  change,  if  there  be  any  source  of  irritation  existing  in  the 
system  of  the  child,  or  in  the  nature  of  its  food,  an  unhealthy  state  of 
bowels  rapidly  ensues.  To  the  consequences  of  this  affection,  mani- 
festing itself  so  soon  after  birth,  nurses  have  given  the  name  of  nine- 
day  cofivtdsions.  Again,  when  another  change  is  made,  and  the  nurse's 
milk  is  left  off,  children  are  also  liable  to  convulsive  fits,  and  these  are 
the  convulsions  of  ablactation.  In  fact,  at  any  period  during  the  first 
year,  infants  are  very  apt  to  get  convulsions  from  various  causes.  If 
the  mother  uses  an  improper  kind  of  food  or  drink,  or  gets  into  a  bad 
state  of  health,  or  be  strongly  affected  by  mental  emotion,  the  quahty 
of  the  milk  will  be  suddenly  changed."^  Under  aU  these  circumstances, 
or  if  the  child  be  over-fed — a  very  common  fault,  the  bowels  get  out 
of  order,  the  whole  intestinal  canal  is  thrown  into  a  state  of  irritation, 
and  convulsive  fits  succeed. 

It  is  necessary  to  be  more  explicit  on  this  subject.     When  you  are 

•  The  custom  adopted  by  some,  of  keeping  the  child  at  the  breast  for  a  year  or  a  year 
and  a  half  is  both  unnatural  and  injurious.  Every  child  should  be  weaned  when  nine 
months  old. 


582  •  CLINICAL  MEDICINE. 

called  to  treat  a  case  of  infantile  convulsions,,  bear  in  mind  that  they 
very  frequently  arise,  particularly  during  the  first  six  months,  from  the 
cause  before  mentioned,  and  this  should,  therefore,  claim  at  once  your 
attentive  consideration.  I  remember  the  time  when  it  was  the  common 
practice  to  treat  every  case  of  convulsions  as  if  it  were  an  hydrocephalic 
attack,  and  when  antiphlogistics,  calomel,  and  cutaneous  irritation,  were 
the  indiscriminate  means  employed  in  combating  every  form  of  this 
disease.  If  a  child  happened  to  get  a  convulsive  fit,  it  was  immediately 
said,  here  is  inflammation  or  congestion  of  the  brain ;  and  leeches  w^ere 
applied  in  successive  relays,  calomel  given  in  large  doses,  egg-shells, 
crabs'  eyes,  magnesia,  and  other  absorbents  administered,  and  the 
unfortunate  infants  cruelly  tortured  by  the  repeated  application  of  blis- 
ters to  the  scalp.  I  have  seen  cases  where  this  blistering  was  carried 
to  such  an  extent,  that  the  child  had  not  a  place  to  rest  its  head 
upon. 

It  is  to  Dr.  Gooch  we  owe  the  valuable  discovery,  that  there  is  in 
children  a  state  of  heaviness  of  head  and  torpor,  accompanied  by  a  ten- 
dency to  convulsions,  in  which  depletion  cannot  be  employed,  and  where 
narcotics  and  even  stimulants  may  be  used  with  advantage.  Doctor 
Locock  asserts,  that  convulsions  of  this  nature  may  be  recognized  by  the 
depressed  state  of  the  fontanelle,  an  assertion  which  I  have  not  verified. 
With  respect  to  leecliing,  I  have  to  remark,  that  a  single  leech  to  an 
infant  is  equal  to  a  bleeding  in  an  adult ;  and  yet  how  often  have  we 
seen  children  leeched  and  leeched,  until  becoming  pale  and  exsanguine- 
ous,  they  sink  as  much  from  loss  of  blood  as  from  the  efi'ects  of  disease. 

With  respect  to  the  causes  and  periods  of  indigestion  in  children,  I 
have  already  spoken.  There  is  one  point  more  which  I  wish  you  to 
hold  in  memory.  Milk  is  a  compound  fluid,  a  beautiful  emulsion  fur- 
nished by  the  hands  of  nature,  in  which  sugar,  oil,  and  curd  are  blended 
wdth  a  certain  proportion  of  water.  Now,  when  a  compound  fluid,  such 
as  milk,  enters  the  stomach,  and  is  submitted  to  the  process  of  diges- 
tion, those  parts  which  are  soluble  in  water  are  absorbed,  and  those 
which  are  not,  become  first  coagulated,  and  afterw^ards  undergo  resolu- 
tion in  the  gastric  juice.  Thus,  while  the  water  and  sugar  are  absorbed, 
the  curd  of  the  milk  is  separated  from  it  by  coagulation,  and  forms  a 
solid  substance,  which  is  acted  on  by  the  stomach,  and  becomes  dis- 
solved by  the  agency  of  the  gastric  juice,  and  in  this  way  contributes  to 
nutrition.  Not  a  particle  of  the  milk,  however,  ought  to  enter  the 
duodenum  until  it  has  passed  through  the  usual  process  of  digestion. 
As  the  first  step  to  the  accomplishment  of  this  is  the  coagulation  of  the 
curd,  this  occurrence  takes  place  with  extraordinary  rapidity :  and  it  is 
a  sign  of  health  if  the  milk  be  thrown  up  in  this  state  immediately  after 


I 


INFANTILE   CONVULSIONS.  583 

it  has  been  sucked.  The  rennets  of  young  animals  give  striking  evi- 
dence of  this  power.  But  if  it  should  happen  that  the  stomach  does 
not  act  properly,  and  the  cui'd  remains  undissolved,  what  is  the  con- 
sequence ?  The  curd  passes  into  the  alimentary  canal  in  a  condition 
different  from  that  in  which  nature  intended  it  should,  and  consequently 
produces  intestinal  irritation.  None  of  the  purgatives  given  to  chil- 
dren are  attended  with  half  so  much  griping  as  this  substance. 

This  explains  the  phenomena  which,  in  such  cases,  present  themselves 
to  our  observation.  The  cliild  becomes  griped,  irritable,  and  feverish, 
his  tongue  is  loaded  and  white,  he  gets  restless,  and  now  and  then 
utters  a  shrill  scream.  In  this  way  the  disease  may  go  on  for  a  con- 
siderable time ;  as  the  child  is  dropping  asleep,  he  starts  suddenly  and 
screams  out,  bends  himself  in  the  form  of  an  arch,  and  tlirows  his  head 
back  as  in  opisthotonos.  I  have  seen  children  in  this  state  for  a  week. 
The  physician,  or  nurse,  gives  castor  oil,  or  some  other  purgative,  and 
a  great  quantity  of  the  curds  are  passed,  and  surprise  the  child''s  rela- 
tives. On  examining  the  discharge,  you  find  it  consisting  of  lumps  of 
different  sizes,  covered  imperfectly  with  bile,  and  having  a  burnt  appear- 
ance ;  on  breaking  them  up,  you  perceive  them  to  be  white  internally, 
and  consisting  of  indigested  curd.  You  remove  them  by  purgative 
medicine,  and  the  child  gets  well. 

Now,  we  all  can  do  this ;  it  is  clearly  laid  down  in  books  :  you  are 
told  to  examine  the  egesta,  and  give  purging  medicine  where  it  is  neces- 
sary. But  there  is  one  fact  which  has  not  been  noticed.  When  you 
have  treated  the  child  in  this  way,  and  the  attack  has  been  cured,  if 
the  child  is  very  strong,  when  put  to  the  breast  again,  he  may  go  on 
well,  and  you  have  no  further  trouble,  but  if  he  is  weakly,  or  of  an  irri- 
table habit,  when  he  is  brought  back  to  the  suck  again,  or  spoon-fed 
with  milk,  the  same  process  of  imperfect  digestion  takes  place,  and  he 
gets  another  fit.  The  physician  is  again  called  in,  and  repeats  the  pur- 
gative, and  the  child  gets  better  a  second  time ;  and,  in  this  way,  the 
physician  goes  on  giving  medicine,  and  the  mother  giving  milk,  and 
every  body  wonders  at  seeing  what  a  quantity  of  foul  stuff  passes  from 
the  bowels.  How  are  you  to  avoid  this  ?  By  making  the  infant  abstain 
from  milk  in  any  shape  for  twenty-four  hours,  sometimes  for  the  space 
of  two,  or  even  three  days.  It  is  incredible  how  small  a  portion  of  milk, 
even  in  the  most  diluted  state,  will  keep  up  this  disease,  acting  like  a 
species  of  poison  on  the  intestinal  mucous  surface.  You  know,  that 
animal  poisons,  such  as  the  variolous,  or  vaccine  virus,  will  affect  the 
system,  even  when  applied  in  a  state  of  extreme  dilution,  and  you  can 
therefore  conceive,  that  a  small  portion  of  milk  wiU  operate  in  this^ 
manner. 


584  CLINICAL   MEDICINE. 

I  attended  a  case  of  this  disease  some  time  ago ;  the  child  had  a 
relapse,  and,  on  being  called  in  again,  I  asked  the  mother  whether  she 
had  given  it  any  milk,  and  she  told  me  scarcely  any.  I  am  always  sus- 
picious when  I  hear  the  word  scarcely  used ;  and,  on  requesting  to  see 
the  kind  of  food  she  had  been  administering,  she  handed  me  a  bowl  of 
barley-water,  wdth  the  usual  proportion  of  milk  and  sugar  in  it :  it  is  in 
this  way  that  we  see  the  disease  prolonged  week  after  week  by  the  pre- 
judices of  the  nurse  and  the  ignorance  of  the  physician.  Well,  if  you 
forbid  milk  altogether,  what  will  you  give  the  child  ?  Let  him  take 
chicken-broth,  barley-water,  thin  panado,  veal-broth,  or  whey.  How 
long  are  you  to  continue  this  ?  The  number  of  days  will  depend  on 
the  power  which  the  child  possesses  of  regaining  the  proper  tone  of  the 
stomach ;  some  children  will  have  the  stomach  out  of  order  to-day  and 
well  to-morrow,  and  the  length  of  time  you  are  to  keep  up  this  diet  wiU 
vary  considerably. 

When  you  are  called,  therefore,  to  a  case  of  convulsions,  inquire  into 
the  history  of  its  symptoms,  the  nature  of  the  alvine  evacuations,  and 
the  quality  and  quantity  of  your  patient's  food ;  and,  if  you  find  that, 
before  the  attack,  the  child's  bowels  have  been  in  a  bad  state,  that  they 
have  been  for  some  weeks  inclined  to  be  loose,  or  that  the  stools  are,  at 
the  time,  similar  in  colour  and  consistence  to  what  I  have  described 
(though,  by  the  by,  you  are  often  told,  that  every  thing  is  quite  right 
when  it  is  not  the  case),  you  will  then  be  able  to  judge  properly  of  the 
nature  of  the  case,  and,  by  giving  aperient  medicines,  you  will  probably 
not  only  cure  the  disease,  but  also  prevent  a  return  of  the  convulsions. 
Sometimes,  however,  the  convulsive  fits  will  remain  after  the  irritating 
sordes  have  been  removed  by  purgative  medicines.  Absorbents  are  next 
made  trial  of.  These  have  a  very  beneficial  influence  in  many  cases, 
they  can  do  no  harm,  and  where  acid  is  present  (and  this  occurs  in  the 
stomachs  of  children  to  a  greater  extent  than  in  those  of  adults),  prove 
mildly  purgative. 

But  if  the  convulsions  continue,  what  else  will  you  prescribe  ?     I 
remember  attending,  not  long  since,   an  infant,   about  three  or  four 
months  old,  who  had  been  for  some  time  under  treatment  for  convulsions. 
Leeches  had  been  applied  to  the  epigastrium ;  it  got  calomel,  castor  oil, 
and  hydrargyrum  cum  creta,  absorbents,  aperient  and  foetid  enemata, 
and  blisters  to  the  vertex  and  stomach.     Still  the  convulsions  went  on. 
Well,  what  did  I  do  ?     1  prescribed  the  following  mixture  : — 
B»     Olei  Terebinthinae,  3j.  ; 
Olei  Ricini,  3iv. ; 
Syrupi  Papaveris  albi, 
Mucilaginis  gummi  Arabici, 
Aquse  foenicuh,  aa,  3U'  Misce. 


MYELITIS.  585 

Of  this  mixture,  when  well  shaken,  exactly  5j.  was  to  be  given  every 
third  hour,  and  what  was  the  result  ?  It  operated  on  the  bowels,  and 
produced  a  copious  discharge  of  urine,  a  marked  improvement  took 
place,  and  towards  evening  the  convulsions  entirely  ceased. 

Dr.  Brereton  informs  me,  that  he  has,  in  similar  cases,  after  the 
bowels  were  evacuated,  succeeded  in  preventing  a  recurrence  of  the  con- 
vulsions, by  means  of  the  following  mixture,  suited  to  a  child  six  months 
old:— 

R     Olei  Anisi,  gtts.  iv. ; 
Sacchari  Albi,  gr.  x.  ; 
Intime  misceantur  et  adde 
AqujE,  5ij.  ; 
Pulveris  Rhei,  gr.  x.  ; 
Carbonatis  Magnesise,  3j. ; 
Tincturae  Opii,  gtts.  iv.  ; 
Spiritus  Ammonise  foetidi,  gtts.  x.  ; 
Sumat  cochleare  unum  medium  tertia  qliaque  hora. 

It  is  to  be  observed,  that  much  caution  is  necessary  in  giving  such 
combinations  containing  opium  to  infants,  but  there  is  a  period  when 
depletion  ceases  to  be  useful,  that  a  mixture  like  this  will  prove  the 
most  effectual  means  of  curing  convulsions.  In  such  cases  of  convul- 
sions, in  addition  to  the  use  of  purgative  medicine,  prescribing  the  mo- 
therms  milk,  and  giving  oil  of  turpentine,  you  may,  during  the  first  24 
hours,  while  the  child  is  strong,  order  a  warm  bath,  applying,  at  the 
same  time,  a  sponge  dipped  in  cold  water  to  the  head  ;  or,  if  the  child 
is  weak,  incline  its  head  over  the  side  of  the  cradle,  and  use  the  cold 
sponge,  and  you  wiU  find  that  it  will  diminish  the  fit. 

Before  concluding  let  me  say  a  few  words  on  inflammation  of  the 
spinal  marrow.  This  disease  is  closely  connected  with  the  subject  of 
neuralgia.  Myelitis  is  so  liable  to  be  confounded  with  a  great  variety 
of  painful  afibctions,  that  every  ascertained  case  of  inflammation  of  the 
spinal  marrow  ought  to  be  recorded  for  the  purpose  of  rendering  more 
perfect  a  department  of  pathology  already  diligently,  but  not  completely 
cultivated.  A  young  married  woman  was  admitted  into  the  Meath 
Hospital,  on  the  12th  of  September,  1838.  She  was  healthy  until  the 
period  of  marriage,  soon  after  which  her  husband  commenced  a  system 
of  ill-usage,  comprising  beating,  kicking,  throwing  down  stairs,  &c.,  &c. 
He  was  frequently  drunk,  and  occasioned  her  every  species  of  grief.  No 
wonder  that  a  life  like  this  should  have  reduced  our  patient  to  the  truly 
miserable  condition  she  was  in.  She  had  been  injured  so  often,  that  it 
was  difficult  to  say  to  what  particular  act  of  violence  her  present  fnalady 
VOL  I.  38 


586  CLINICAL    MEDICINE. 

ought  to  be  referred.  She  is  much  emaciated,  respirations  hurried,  and 
pulse  very  quick.  Has  no  headache,  but  complains  much  of  agonising 
pains  in  the  loins,  aggravated  by  pressure  of  the  lumbar  spinous  pro- 
cesses, extending  round  the  abdomen,  and  downwards  to  the  hips  and 
thighs.  There  is  no  pectoral  affection,  and  her  tongue,  state  of  stomach, 
and  general  appearance,  are  not  those  of  a  person  labouring  under  fever. 
She  writhes  in  the  bed  from  the  violence  of  the  pains ;  she  does  not 
sleep  night  or  day,  and  disturbs  the  other  patients  by  her  cries. 

Blood  was  drawn  by  cupping  from  the  loins ;  leeches  were  applied, 
and  Dover^s  powder  administered.  Her  extreme  emaciation  prevented 
us  from  adopting  either  more  active  depletion  by  the  lancet,  or  the  use 
of  calomel.  In  short,  we  sought  to  reheve  not  to  cure,  for  her  death 
appeared  inevitable.  Blisters  we  could  not  apply  on  account  of  the 
great  emaciation.  On  the  15th  we  found  that  she  had  been  screeching 
all  night,  and  constantly  wanting  extract  of  opium,  which  was  ordered 
her  as  a  palliative.  On  the  16th  she  complained. that  the  sense  of  feel- 
ing was  leaving  her  thighs,  and  she  died  on  the  18th,  five  days  after 
admission.  On  dissection  ^q  found  all  the  viscera  healthy;  there  was 
extreme  atrophy  of  the  intestines,  especially  the  colon  and  caecum ;  so  it 
is  probable  that  starvation  was  among  her  afflictions.  The  lower  portion 
of  the  spinal  marrow  and  the  cauda  equina,  exhibited  an  excessive  vas- 
cularity and  redness,  but  no  exudation  of  lymph.  Each  nervous  fasci- 
culus of  the  Cauda  exhibited  a  vein  on  its  posterior  surface  distended 
with  blood  ;  and  the  remaining  portion  of  each  fasciculus  displayed  great 
arterial  vascularity. 


END    OF    VOL.    I. 


DUBLIN: 

GOODWIN,    SON,    AND    NKTHEllCOTT,    rillNTEHf 
MARLBOROUQH-SrRKKT. 


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